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.

Fox’s The Resident: Everything Stereotypically Bad About Hospitals (Part 2/2)

Today, I’m continuing my review of Fox’s new medical drama The Resident and all that is bad about it. You can find Part I here.

Let’s continue our list.

THE RESIDENT: L-R: Manish Dayal, Emily VanCamp, Shaunette RenŽe Wilson, Matt Czuchry, Valerie Cruz and Bruce Greenwood in THE RESIDENT premiering midseason on FOX. ©2017 Fox Broadcasting Co. Cr: Justin Stephens/FOX

Bargaining with IV drug users for drugs. In one scene, the younger protege is seen bargaining with an IV drug user so that she’ll give into his demands and it becomes a bartering of sorts like buying food in an open market. Hands down, the physician should decide what his bottom line is and not waiver from it.

Effective CPR is “until the ribs crack”.  Effective CPR is just the amount of compression depth it takes to generate a pulse that can be felt. It is a risk factor that the patient’s ribs can break, but it is not the clinical guideline we shoot for.

An environment of “no questions asked” is dictated. The senior resident gives his junior resident this mantra: “Do what I want you to do. No questions asked.” Again, this type of environment is intolerable in the hospital setting and should never be dictated . . . like ever. A questioning environment has been shown to increase patient safety and smart hospitals are encouraging this very thing. Most hospitals also have a mechanism in place to go above the bedside medical team if family concerns are not being addressed.

A surgical resident get first dibs on the new, bright, shiny, robotic surgical wonder. Need I say more?

The attending surgeon pretends to do a surgery. Remember the new shiny surgery robot? Remember the attending from Part I that has obvious hand tremors and should not be doing surgery? Did I mention this attending surgeon is an ego maniac (he even leaves positive medical reviews for himself)? Well, since no one has ratted out this well . . . rat . . . it must be him that first uses the machine. However, physically, he can’t do it. So he sets up a ruse where it appears he’s doing the surgery where in reality his uber smart, highly capable resident is. I cannot tell you how ethically bad this is on so many levels.

There are several issues that surround a lengthy medical code in the ER. The IV drug user that bargains for drugs in the beginning codes related to a heart infection. She is coded for nearly 30 minutes— the junior resident keeps it going for that long because of his emotional connection to the patient. Of course, just as he decides to call it, the patient gets her pulse back.

The senior resident is mad at him because he’s just revived a “vegetable”. Honestly, it is the senior resident’s job to watch their underlings. There would have eventually been an attending doctor overseeing this code. So, the person least responsible for the length of this code is the junior resident. Everyone higher up on the totem pull has the ability to stop the code.

Hospitals keep vegetative people alive for money. This is so patently false it’s laughable, but is probably more believable for the general public because many think hospitals will do anything to meet their bottom line.

I’ve been in nursing twenty-five years this May. I first started in adult ICU nursing and in that unit in Kansas there was avid discussion of clinical pathways to put people on to withdraw unnecessary (futile) care. In fact, I would say I’ve seen the opposite— at times a push to take people off of life support sooner then may be warranted from both the family and/or medical providers.

A resident taking it into their own hands to discontinue life support. Because the patient has no hope for life and he sees that the family is in no hurry to stop life support, the resident decides to turn off the machines. Fortunately, he is caught by a fellow resident and quickly turns back on the life support and the patient suffers no ill effects. Again, highly unethical. How about . . . having some hard conversations with the family about the viability of their daughter and helping them come to this decision? I know this is painted in the episode as a merciful thing for this doctor to do, but it would have been murder if he succeeded. He does not have permission to discontinue life support and cannot do so on his own accord. Period.

Also, there is no reason to be dumping a bucket of ice cold water onto a patient’s face . . . like ever.

I guess I should be thankful to The Resident for giving me all this blog material. It’s the only thing good about the show.

Tell me what you think of The Resident? If you’ve seen an episode, will you keep watching?


Pediatric CPR: When to Stop?

Nothing probably tugs at the heartstrings more than thinking about a child dying. It’s not the way things are supposed to happen. We expect life to follow the natural order of things— the old die first. Parents should never bury their children.

Sadly, we know this reality is not true. The pediatric nurse understands and confronts this reality more often than most. Particularly nurses who work critical care, ER, oncology, and hospice.

A reader of this blog posed this question to me: How long will a nurse or doctor perform chest compressions on a pediatric patient? Is forty-five minutes too long or would they try longer?

This is a tough question and not so easily answered. There are really no hard and fast rules as to when CPR should be stopped and it depends a lot on the reason for the code (if known) and what types of signs the patient is giving us. For instance, just because a patient doesn’t have a pulse, doesn’t mean they don’t have electrical activity in the heart muscle. Some causes of a code are reversible, but it takes time to do so. Hypothermia might be a good example of this.

I’ve worked in both adult and pediatric critical care. What I’ve found generally is providers will run pediatric codes longer than adult codes even when chances are small to get a pulse back. No one wants to see a kid die— health care providers are no different. Plus, culturally, we resist death at every turn even though it is the course each of us will journey to.

However, I did come across this article that begins to address this concern. If we can teach how to resuscitate patients— should we also not teach providers when it is reasonable and ethical to stop such efforts?

1. Are there clinical features present prior to the code that are predictive of poor survival? For instance, in the adult patient some of these from the article included pneumonia, metastatic cancer, and low blood pressure. For pediatric patients, kidney failure and use of a continuous infusion of epinephrine are mentioned.

In the emergency department setting, we want to know what the patient’s initial heart rhythm was. If there was no electrical activity in the heart (terms such as asystole, flat-line, ventricular standstill) then chances of getting back organized electrical activity AND contraction of the heart muscle are low.

2. Is the patient receiving high quality CPR? This might seem like a no brainer. Of course, if the patient codes in the hospital, they must be receiving excellent CPR. What research shows is that this is not true and it is a big drive of many institutions to simply improve the quality of CPR. If I can ease your mind, many hospitals are improving CPR basics through high fidelity code labs, more frequent CPR check-offs, mock codes, and computer based CPR training that measures effectiveness of CPR and coaches the participant on how to improve .

What are some CPR pitfalls? Initiating CPR in a timely manner. Compressing deep enough and at the right rate. Not over or under ventilating the patient (both can actually cause problems). CPR is what we call a high risk, low yield procedure— meaning we don’t do it very often, but when we do we have to do it right. What you don’t practice frequently you don’t become adept at. CPR is no different.

Considering this, we look at how long the patient’s down time was. This refers to the time when the patient’s heart stopped beating to the time they got CPR. Trouble is, this might be relatively hard to determine. When was the patient last seen? Is the patient cold to the touch? Are their pupils fixed and dilated?

The good news for the writer is there is a lot of leeway in this area as far as how long a medical team might “work” on a patient. Factors can be given for both short and long resuscitation times.

The most important part is getting those factors medically correct.

What about you? Have you written a resuscitation scene into a work of fiction?


Can You Commit Suicide With an AED?

Recently, my husband and I have been binge watching through all five seasons of breaking-bad-s5-400x600-compressedv1Breaking Bad. In the last season, a gentleman decided to kill himself using an AED.

AED stands for Automatic External Defibrillator. It is a quick rescue device used mostly by non-medical people for cardiac arrest. It is designed to recognize lethal heart arrhythmias and deliver a shock (electricity) if the patient is in one. The AED will not always fire. In fact, there are really only two arrhythmias it is designed to treat.

The question becomes, can you use an AED to commit suicide? An AED has two large, white patches connected to the device. In the show, the gentleman places one patch on his chest, pulls off the other patch and places the exposed wires in his mouth. After this, he turns on the device and discharges it, thereby killing himself.

aedThis scenario is highly improbable and here’s why:

1. Both patches must be in place for the defibrillator to analyze the patient’s rhythm. If they’re not, the machine will not progress any further.

2. Let’s say the AED would read the rhythm (one patch on the chest and exposed wire in the mouth)— it won’t deliver electricity for a normal rhythm (which this gentleman likely has because he’s alert and conscious.)

3. Let’s say the AED did fire for his normal heart rhythm— would he die? There is a slight chance that he might die, but only if the AED fired during a very sensitive time in the electrical cycle of his heart which has a very low probability.

All in all, I don’t find this method of suicide possible. Sorry, Breaking Bad, though I did love the series.

How Hard Is It To Do CPR?

Some of the questions you get asked as an ER nurse are very interesting. Some I can talk about . . . and some I can’t. One fairly consistent question is, “How hard is is to do CPR on someone?”
It’s hard people . . . flat out hard. 
The goal of CPR is to do the work that your heart does from the outside of the body. Keep in mind all that protects your heart from getting injured: layers of skin, fat, muscle and bone. All that has to be overcome to squish the heart enough for it to generate blood flow. 
Research has proven two things. The first is that CPR done effectively is the best thing that can be done to save your life if you go into cardiac arrest. Every minute you go without CPR your percentage of survival decreases precipitously. The second is that the effectiveness of one person doing CPR also significantly decreases after about two minutes which is why the American Heart Association encourages changing out those people doing compressions every two minutes. 
This story of an EMT suffering a stroke after performing CPR for 30 minutes highlights how much exertion a body sustains from performing chest compressions. 
So, there is a definite balance between doing effective CPR with the amount of physical strength you have on hand. 
Studies are also showing that continuous CPR, without pausing for breathing, is also increasing a patient’s likelihood of survival. Some EMS organizations have gone to doing two continuous minutes of CPR immediately upon arrival and then going into the appropriate advanced life support protocol. 
The newest approach is what is called Pit Crew CPR. Just as in car racing where everyone has a defined role and becomes an expert at that role– the same is true for this style of CPR. The importance of this method is that there is little pause in compressions. The concern with stopping CPR is that it takes anywhere from 15-30 compressions to get pulsatile flow again which is never good for the patient in cardiac arrest. 
In Salina, KS where they’ve trialed this their rates of return of spontaneous circulation (getting back a heartbeat) increased from 44% from 32%. That may not seem significant but it is a tremendous leap in terms of resuscitation medicine. Each of those points is a person living
Basically, in Pit Crew CPR, two people alternate compressions at either side of the chest. The person at the head of the patient manages the airway but initially the patient is placed on oxygen but there is not an emphasis on providing breaths as in traditional CPR. One person at a leg manages the defibrillator and a provider at the other leg establishes IO access (drilling an IV into the leg). 
After a few minutes of this style of CPR if the patient doesn’t have a return of their pulse, they are placed on an AutoPulse and transported to the hospital. 

New Medical Device: Zoll R Series Defribillator

It’s difficult for new medical devices to impress me. This one did.

One of the challenges in medicine is doing effective CPR. Research studies have consistently shown that what generally saves a patient’s life is early and effective CPR. That’s when all the other bells and whistles that we have in our medical stockpile will work.

However, you might be surprised at how ineffectively we do CPR. For one thing, it’s physically hard to compress the chest enough to generate a pulse. Second, it’s tough to measure the effectiveness of compressions. The way this is traditionally accomplished now is through palpating a pulse during CPR (which is difficult to do accurately) or to measure what’s called end tidal CO2 which is best accomplished when a patient has a breathing tube down their trachea.

Another difficulty in doing CPR is the amount of artifact it creates. Artifact is something you see on the monitor that isn’t a true representation of the patient’s condition. For instance, if a patient is connected to a monitor and you pick up their ECG leads and shake them– you can make it look like they’re in a lethal cardiac rhythm.

If you’re doing effective compressions, you can’t see the patients underlying rhythm but stopping CPR to check a patient’s rhythm takes away from its effectiveness as well. It takes a while to establish pulsatile flow with CPR so every time you stop, the patient can suffer.

The Zoll R Series Defibrillator attempts to change some of these issues and if it is able to do what it says– it could mean a big improvement for patient care.

It has a pad that is placed at the center of the patient’s chest. This measures the effectiveness of compressions and makes sure they are at the right rate and depth. It also allows you to see the patients underlying rhythm while compressions are ongoing which can lead to better treatment at the bedside when a rhythm changes.

It will be interesting to see if a device like this will decrease the morbidity and mortality around code events.

I was not paid by the company to review this product.

Author Beware: Use of Electricity

Authors, television producers and scriptwriters are fascinated by the use of electricity. This is probably one of the most commonly abused medical scenarios in that it is rarely used correctly.

One of my most popular posts here at Redwood’s was a post titled Shock Me To Death that highlights how electricity (or defibrillation) should be used.

I was reading a debut novel by a medical doctor and found many grievous errors around the use of electricity. Which distresses me because he also said he had a cardiologist review the manuscript. Seriously, I kind of want to know who that doctor is and what kind of training he had.

There was the usual error of shocking a flatlined patient or asystole. Remember, in order for electricity to work, there has to be some present. If a patient is flatlined, there is no disorganized cardiac rhythm to reset and so defibrillation is contraindicated in those patient scenarios.

Next error in this manuscript was cracking the sternum down the middle during compressions. For one, the sternum is extremely hard to fracture. It’s designed to protect some very important organs. If the sternum is even slightly fractured, we know there have been extreme forces placed on that patient. So, to have mere hands fracture a sternum all the way down the middle is ludicrous. Remember, they saw this open for open heart surgery. Breaking ribs is very probably during CPR, but not the whole length of your sternum . . . sorry.

Last, and most creatively (as I’d never seen this error before), was the amount of electricity used in an ICD device (an implanted cardiac defibrillator.) ICD’s are devices that are used to convert patients from lethal arrhythmias like v-fib and v-tach. They are not pacemakers– which stimulate the heart to beat.

Whenever electrodes are placed near the heart, the amount of electricity used is very small. Think about it. When we shock you from the outside of your body, the electrical current has a lot of tissue to pass through to get to your heart. This is why we use more. When defebrillating someone– it’s in joules.

A pacemaker uses a lot less energy. Outside pacemaker use milliamps.

And here is the very interesting quote from a published novel:

“Cardiologists shock patients all the time under controlled conditions, remotely dumping up to 700V (volts) of juice directly in to the heart via the ICD.”

Wow. That’s just . . . overkill.

Just how lethal is 700 volts applied directly to the heart?

This site explains that 110V can kill you.

It’s so egregious an error that I’m not quite sure what this author was thinking. It pains me more that he is an actual medical doctor. I even double checked the published manuscript (as I’d read a galley proof before) and the error was still present.

I think he needs a new cardiologist.