Emergency Medicine

When a Cardiologist Becomes a Heart Patient: Dr. Paul C. Ho

/ Jordyn Redwood / Leave a comment

Today, Redwood’s Fans, I have a special guest blogger for you. Dr. Paul C. Ho is a cardiologist who suffered a heart attack which led him on a journey of self discovery. Today, he shares his thoughts here and I hope you’ll check out his book, Art on the Human Heart.

Welcome, Paul!

I’m a board-certified cardiologist and a cardiac arrest survivor—a heart doctor who became a heart patient. I believe these experiences make me somewhat of an expert storyteller from both a doctor’s and a patient’s point of view. As I reflected on playing these dichotomous roles in the health-care arena, the story of my autobiographical novel, Art on the Human Heart, came to be.

Aside from its anatomy and physiology, are there other functions or meanings to the human heart? The ancient Egyptians and the ancient Greeks considered it to be the seat of emotions. The Bible says, “In the heart dwells feelings and emotions, desires and passions. . . . The heart is the seat of the will and understanding.” For millennia, this centrally located organ has been implicated in our perception of the outside world and capable of generating a behavioral response to our feelings—the very essence of our presence, our being.

But which is the chicken or the egg? The age-old question applies here to the “emotional” aspect of the heart. When we are happy, the heart feels a sense of openness and a certain lightness. Conversely, anger can bring troubling heart palpitations and chest tightness. There is no doubt that “heart emotions” can be influenced by outside stimuli—whatever makes us happy or angry. But could the heart itself be the originator of feelings that may alter behavior and outcome? Is there then a true nature of the human heart?

As a cardiologist, my professional focus is on the physical nature of the human heart. As we all know, unhealthy life habits, such as cigarette smoking, eating fatty foods, and lack of exercise, can lead to the development of acquired heart diseases. Parallel to outside forces influencing heart emotions, external factors can also affect physical changes in the heart. What if the intrinsic nature of the heart can lead to the development of heart disease? For example, in an innately angry or unhappy heart, could the negative emotional tone trigger early heart ailments? Surely in medical literature, we are seeing an increase in reports of such associations.

When I suffered my own heart attack, I was only thirty-nine years old. I was young, living a healthy lifestyle, and did not have a predisposing genetic factor for heart disease—there was no obvious medical cause for my near-fatal condition. Why then did I almost die at thirty-nine? I questioned if the nature of my heart had something to do with it. At the time, I was extremely hard-working and had an angry, perfectionist, and type A personality. Was I subconsciously dissatisfied with my life? Was I unaware of deep-seated unhappiness? Could that have been the cause?

To better understand what happened to me, I wrote my novel to explore the true nature of the human heart through the eyes of a high-powered, high-stress cardiologist. When I became sick, my compassion turned inward toward myself for the first time in my life. Recognizing that well-being goes beyond conventional medical treatment, I dug deeper into the meaning and nature of our hearts. What truly makes us happy? What truly makes a healthy heart? To save ourselves, as I tried to do in the aftermath of my heart attack, we must understand the true nature and desires of our own hearts— nobody else can do this work for us.

I hope you will enjoy my book and learn as much as I did about our true hearts.

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Dr. Paul C. Ho is a cardiologist and a heart attack survivor. He has published numerous medical papers and is a reviewer for several medical journals. Art on the Human Heart is inspired by his love for creativity, exploration, and self-discovery. Dr. Ho studied engineering and medicine at the University of Pennsylvania, Temple, Dartmouth, and Harvard. He was the chief of cardiology in a hospital system and was awarded several patents for his medical device inventions. Dr. Ho enjoys traveling to remote places and has worked in native communities including locations in Alaska. He lives in Hawaii with his pooch, Bear-Bear.

Author Beware: Good Example of BAD CPR

/ Jordyn Redwood / Leave a comment

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?

Author Question: Details for Chest Tube Placement

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Rachael Asks:

I’m sure you get questions on this all the time, but I was wondering what insight you can provide on traumatic wounds. My project is science fiction and the characters in question have enhanced healing and a sped up metabolism which I’ve just been using as my cure-all, smooth-over for any inaccuracies thus far. But then I found your blog- which has been incredibly fascinating and entertaining.

The first question I had which led me here was in general for a gunshot wound to the chest though not involving the heart. Namely, the various potential complications, the meds, supplies, or procedures that may be employed, and the sorts of phrases and terminology and reactions that may be overheard from the staff working on the patient. I’ve read on the risks of things like a sucking chest wound and consequential lung collapse, punctured lung, of course blood loss, but I still am at a loss for particularly the things the medical staff on hand would be saying or doing. (Bonus points if you have any tips for the internal monologue for the victim besides “ow.”)

Jordyn Says:

Hi Racheal! Thanks for sending me our question.

Your question is hard to answer. You don’t give specifics of the injury though it looks like you’re leaning toward a collapsed lung. There are a couple of ways you can research the feel of an emergency and that is by watching reality based (non scripted) shows that center on emergency medicine or look for teaching videos (or live videos where they capture the procedure on a real patient on You Tube).

For instance, a patient with a collapsed lung will likely need a chest tube placement. You can search You Tube for “placement of a chest tube” and see what comes up. The below video is pretty good as it gives lots of technical detail on what the physician is doing, seeing, feeling, and even what medicines might be prescribed for the patient. However, it does lack a lot of language of what would be said to the patient during the procedure.

The next video shows more patient interaction and what might be said. Between these two videos you could probably extrapolate together a scene. I will say that typically patients are connected to a larger suction device, but what the below physician is connecting to looks to be a more portable device so the patient can be up and walking. Also, a patient with a tension pneumothorax who is crashing may not receive local anesthesia and may even be unconscious.

Your best option, once the scene is written, is have a medical person who actively is practicing in the field review it. If your scene is written from the POV of the doctor placing the tube, it would need to be more technical versus if you’re writing it from the POV of the patient. You can also search Google for patient experiences of having a chest tube placed to get a feel for the inner dialogue you’re looking for.

Hope this helps and good luck with your story!

Author Question: Multiple Survivable Stab Wounds

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Joseph Asks:

I am writing a story inspired by the Saw franchise in which a man is forced to stab himself with three Swiss army knives. The knives will remain in. For the best chance of survival, should all the stabs be in the lower abdomen, or also bladder and/or hands/forearms?

I’ve heard the hands, forearms and lower abdomen are the three safest places to survive a stabbing, although of course technically there is no safe place, but those three areas avoid major organs/arteries/blood vessels. Though I’ve also heard stab wounds to the extremities i.e. hands can cause lasting disabilities. Where should he stab himself and how long until he is expected to die? He will be able to call an ambulance immediately, and maybe could use some cloths nearby to help put pressure on the wounds, assuming the pain is not debilitating.

Jordyn Says:

Hi Joseph!

Thanks for sending me your question.

I would agree with most of your assumptions as far as the extremities in general and the lower abdomen. You don’t include the legs. I think another relatively *safe* area would be the front of the thigh into the muscle or the back of the calf. Anywhere in the extremities where there is a large muscle mass. You could browse anatomy pictures of the extremities looking for diagrams of where the arteries are located to make sure you avoid them.

The lower abdomen is a good choice as well for suvivability. The problem can be puncturing the intestines and spilling gastric contents into the the abdominal cavity. If this happens, this can set up infection and sepsis though this would take a couple of days. You mention in your question that your character will be able to call for an ambulance immediately, not sure if that’s what you intended to say, as a delay in calling for an ambulance would definitely increase the conflict in your story.

Next to bleeding out, developing infection and sepsis would be the greatest risk of death for this character, but would likely take 2-3 days to develop.

Any stab wound to the hands or feet could be a set up for a life long debilitating injury. Many of these can be repaired, but I personally ruptured a tendon in my hand over twenty years ago and have limited range of motion to that thumb. The decision to make as the author is what, if any, long lasting effects you want the character to suffer.

Hope this helps and best of luck with you novel!

 

Author Question: Pedestrian vs. Truck 2/2

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Today, we’re continuing with Luna’s question. You can view Part I here. In short, a 24 y/o woman has been hit by a truck throwing her into the air. When she lands, her head hits a concrete divider.

What will the doctor check or say when she first arrives at the emergency department?

If EMS care has been provided as I outlined in the previous post, we would do the following in the ER:

  1. Check vital signs and level of consciousness. If vital signs are abnormal, we would address those immediately. For instance, if her oxygen level is low, then we’ll provide more oxygen and evaluate whether or not the patient needs to be intubated (a breathing tube into the lungs). EMS may have already done this. If so, we’ll check the placement of the tube. If her blood pressure is low address that by giving either more fluids, blood, and/or a vasopressor (which is a medication given via a continuous drip to raise blood pressure). Of note, sometimes giving lots of IV fluid with head injuries is problematic.
  2. Draw lab work. In this case, we would check multiple labs. Blood counts, chemistries, and labs that look at how well the blood is clotting.
  3. Radiology studies. This patient automatically buys herself a full spine series (looking for fractures in the spinal cord) and a head CT (that would look for bleeding– and other things). Other labs and studies would be ordered depending on what other injuries were found. As previously stated, this patient would likely have more than just the head injury. A chest x-ray as well particularly if intubated to check placement of the tube.

Is surgery needed? 

This would be up to you as the writer. Would there be a case in this scenario where surgery might be indicated? Yes. Hitting your head into a concrete barrier could definitely cause some fractures in the skull where bone fragments could enter the brain. This patient would get a neurosurgery consult for sure.

Does she require blood transfusion for the surgery? 

Whether or not a patient gets blood is largely dependent on what their blood counts are. We look at this by evaluating a patient’s hemoglobin and hematocrit or H&H in medical lingo. If low, the patient gets blood. In trauma patients where there is a concern for bleeding, we draw blood every few hours to trend this lab. If it’s dropping, we know the patient might be bleeding from somewhere.

What machines would be used to keep her alive?  

In this case, likely a ventilator (or breathing machine).

How long will she be in the hospital? I am writing for two days.

Unfortunately, I think this patient would be hospitalized much longer than that. A brain injured patient that requires brain surgery would likely be hospitalized for a week or more. A week on the short end if they wake up and are neurologically intact meaning that they can speak, walk, and talk. That they know who they are, where they are, and what time they are in. Also, are their cognitive abilities intact (memory, ability to do simple calculation, etc). If this patient had a simple epidural bleed, then perhaps home in a few days if the above is normal.

The reason I say a week for this patient is the concern for brain swelling surrounding this type of injury. Brain swelling peaks around 48-72 hours and patients generally get sicker when that happens.

Thanks for reaching out to me, Luna! Best of luck with this story.

New Amsterdam: A Problem with Repetition

/ Jordyn Redwood / 1 Comment

For you, my faithful reader, I took in the latest foray into the medical drama by watching New Amsterdam. I was hesitant because of being burned recently by The Good Doctor and The Resident. I know, some of you are loving those two shows, but let’s try to be somewhat medically accurate if you’re going to write a medical drama.

Anyway, I decided to give New Amsterdam a try. It stars Ryan Eggold as bright and shiny new medical director, Max Goodwin, at the healm of a safety net hospital called New Amsterdam. He’s a flawed character, which I liked, and he’s in charge of a staff where they’ve had a new medical director every year for the last five years.

Of course, his moral center is to upend the system for the benefit of patients and not necessarily the gain of money. This is in itself strange since they make it a point to say this is a public service hospital— which still needs to worry about money— but the feeling is different than working at a for profit hospital.

To carry through his moral center, he needs to make big changes fast. I’ll step through some of what I found problematic with the first episode, but I was intrigued enough to keep watching so I’ll keep you posted.

Problem One: One of his first acts as medical director is to fire the entire cardiothoracic surgical team— like every. single. one. Put aside that generally there are a lot of hoops to go through when firing anyone, particularly a doctor, this action puts the hospital at risk of not being able to serve the people he wants so desperately to save. Level I trauma centers must meet certain requirements in order to keep their doors open and firing the entire cardiothoracic surgical team is going to put this in significant jeopardy.

Problem Two: Committing a patient to inpatient psychiatric treatment to keep her out of foster care. Again, as with my recent post on the movie Unsane, there are strict laws on how long you can involuntarily commit someone and generally it needs to be reevaluated on a weekly basis. So, though commendable (because she does like the staff where she is and it would keep her safer than where she’s been), it’s just not feasible that any scenario like this would ever pan out.

Problem Three: Saying the same thing, but fancier. Sometimes I wonder who they find to be medical consultants for these shows. There must be someone. Then I wonder who this someone is and what is the nature of their medical background. In two different areas of the show, the doctor is basically saying the same thing.

Here are two examples:

1. “The patient got diazepam and Valium.” Okay, awesome. These are exactly the same medication. So, you gave the same drug twice?

2. This is a set of orders given by an ER physician. “I need a CBC, BMP, Chem 7 and a saline lock.” Sweet! A CBC is a complete blood count, however a BMP (basic metabolic panel) and a Chem 7 are the same test.

Overall, an intriguing show and I’ll give it another try, but I’m also available for medical consulting!

Video on Treatment of Excessive Bleeding

/ Jordyn Redwood / 1 Comment

Since I get LOTS of questions regarding bleeding, I thought this would be a nice instructional video to post regarding treatment of excessive bleeding.

The post is mildly political at the beginning and does contain some profanity (bleeped out), but at the end it is a great discussion of controlling bleeding— particularly use of tourniquets.

Thanks ZDogg, MD for the great information and keep up the good fight.

911: Let’s Provide Some Medical Care

/ Jordyn Redwood / Leave a comment

In the Season Two/Episode Eight airing of the FOX television show 911— there was a great scene on how to really provide no medical care.

The setup: A gay couple is getting ready to go on a bike ride. Much time is spent in a musical montage showing their lives together. It’s clear they have had a loving relationship and remain deeply in love. One gentlemen goes to load a bike onto a SUV when, in a series of unfortunate events, he gets pinned by the SUV to the entrance gate— akin to Anton Yelchin’s accident (though they do show in the episode the SUV was placed in neutral).

He is discovered by his partner who then calls 911. Upon arrival, there isn’t much done for his lover. He is essentially declared dead on arrival.

Then, the gentleman who discovered his partner, goes unconscious while a firefighter has his back turned. Literally only a few seconds have expired when the firefighter discovers he’s passed out. They provide one and a half cycles of CPR and kind of shrug their shoulders declaring that he’s died, too.

This is unacceptable management of this patient. It’s essentially a witnessed arrest so they were correct to start CPR immediately, but at the very least, he should have been connected to an AED for rhythm analysis and probable defibrillation. A very common reason for sudden collapse are arrhythmias that will respond to electricity. There’s no reason why this gentleman’s treatment  should have been so sparse. It would have increased the drama and the tension of the episode to have this patient get a full resuscitation.

Lifetime Movie Killer Twin: Killing Nice People Needlessly

/ Jordyn Redwood / Leave a comment

As with all television networks these days, the Lifetime Channel could use a good medical consultant as well. In a recently aired movie, Killer Twin, not only (Spoiler Alert!) does the main character, Kendra, have an maniacal unknown twin sister trying to end her life . . . the writers aren’t helping her out too much either.

There will be spoilers for this movie in this post so you’ve been warned.

The plot revolves around the heroine, Kendra, whose life is perfect. She was a twin, but the adoption agency didn’t disclose that and she was adopted as a single child, leaving her twin sister to suffer in the foster care system. Now her twin wants her life and wants Kendra dead.

The main attempt to do this is to expose Kendra to poppy seeds, of which she is deathly allergic to, via a conveniently delivered fruit basket— oh, and steal her epi pen so she can’t save herself.

Thankfully, Kendra’s mother is with her and calls 911, but the attempted murder plot lands her in the hospital.

Here are the following problems with this scenario.

Problem One: Twins aren’t necessarily allergic to the same thing. Can they be? Sure, but it would have to be proven out. For instance, if a mother were to tell us in the medical sphere that a patient’s twin sister is allergic to penicillin, but the patient has never had it, we would still give it a try. It’s presumptive in this movie to assume that because evil twin has the allergy, so would the good one.

Problem Two: Unnecessary Hospitalization. It’s actually very rare for a person having an anaphylactic reaction (which is life threatening if untreated) to land in the hospital. Most of the time, they are observed in the ER for several hours and sent home with medications to take over several days. I’ve outlined the treatment for anaphylaxis in this post. Also, the heroine, who is six weeks pregnant, is told that the medical team admitted her overnight because “a lack of oxygen and toxins could hurt the baby.”

First, let me mop up the blood that just shot forth out of my eyes.

Poppy seeds are not a toxin. They’re a food item. There’s no evidence given in the movie that the character stopped breathing and therefore suffered a loss of oxygen. If you claim this— let’s at least put the character on a monitor to watch her oxygen levels. Lastly, you can’t monitor a baby at this point in any way and isn’t a justification for staying in the hospital.

Problem Three: Killing people with the wrong IV solution. The picture on the right shows the IV solution they were “running” on her (explained in the next section) which is sterile water. Flat out, this will kill people for reasons I won’t go into here. It is never used as an IV solution.

Problem Four: The IV tubing goes into the pump. Honestly, if you’re going to park a piece of medical equipment at the beside, and have a nurse check on it, then know how to use it. As noted in the photo, the IV tubing is not loaded into the IV pump.

Sadly, sweet Kendra doesn’t need her evil twin to kill her, the writers are doing their best on their own with this medical set up.

 

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

/ Jordyn Redwood / Leave a comment

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.