Author Question: Treatment of the Burn Patient

Jennie Asks:

What happens when someone gets burned? What do the EMT’s do on the scene? The story line involves the explosion of a crosswired electrical box.  Two individuals are burned.

First, the man who threw the switch is thrown onto the floor and sparks are showering down on him and his clothes.  He is pinned beneath a shelf that he knocked over.  The second man takes his jacket and tries to put out the flames while others pull the shelf off the man on the floor.  The second man’s arm and hand are burned trying to put out the fire, and keep the sparks from falling on the man on the floor.

I have the paramedics taking the first man to the hospital. I describe very little about his condition. However, the hero is attended by the heroine who is an EMT. His burns are secondary. Would he have to go to the hospital?  Get a tetanus shot if he needs one?

Jordyn Says:

The first distinction to make is that there are several different types of Emergency Medical Service (EMS) providers and their level of responsibility to this patient will be different. An emergency medical technician (EMT) generally provides basic first aid, CPR, can administer oxygen and can assist the patient in giving some of their own medications (like an asthma inhaler or nitroglycerin tablets.) A paramedic does more advanced medical procedures and gives drugs. The level of your provider will need to be clear in the medical care they can provide.

For EMT’s, in general, burn care is as follows:

1. Remove clothing from the burn that is non-adherent.

2. Remove any constricting items. For instance, if the burn is on the ring finger, you would try and take the ring off.

3. Cover burn with a cool, wet, clean dressing. This will help control pain.

If you have a paramedic responding— it is possible that an IV could be started and the patient could get an IV narcotic for pain (something like morphine or fentanyl.)

If the character is burned by the electrical current, this poses a whole new set of problems. I get the feeling he is burned by the electricity because you mention that he has been thrown back. Electrical burns typically have an entrance and an exit wound like the hand and foot. The electricity enters one part but has to exit somewhere.

The other problem with electrical burns is that your heart pumps based on an electrical conduction system. An electrical burn can injure the electrical conduction system of the heart and we will look very closely at whether or not the heart sustained injury. This could be evaluated initially by a 12-Lead ECG and lab work that measures muscle breakdown specific to the heart. The issue with electrical burns is that the damage is often unseen because the electricity will injure you internally but we can’t see it externally except and the entrance and exit sites.

The other thought was the extent of your patient’s burns and this would make a difference in their medical care. Burns are generally calculated based on the percentage of skin that is affected. You can find examples of these tables by clicking this link. Adults and kids are calculated differently.

Burns <15% body surface area (BSA) would get cool, moist compresses. However, burns > 15% would get dry, sterile dressings. The reason for this is that burn patients have lost their skin integrity. Your skin helps your body maintain its temperature. Some consider it the largest organ in the body. When you burn >15% and apply cool, wet dressings, this can pull enough heat away from the patient to cause them to become hypothermic. We actually have to help burn patients maintain their body temperature by cranking up the heat in the room or using other warming techniques.

Your patient will have to go to the hospital. Initial ED treatment would be IV placement, fluid resuscitation (there is a formula we use for this and is dependent on the burn percentage), pain medication (like morphine), and likely consulting with a burn center to help determine his course of treatment. Tetanus shot would be updated if he hasn’t had one in the last five years.

Did you know that paramedic protocols are relatively easy to find online? For instance, this link shows all of the Denver Metro Prehospital Protocols. Referencing these will be one of the best sources for researching what type of prehospital care your character would receive for their given ailment.

***This content originally posted December 10, 2010.***

Author Beware: The Right Patient Placement

Coming across inaccurate medical scenarios in books is common for me so to have one raise my ire enough to blog about it generally means a pretty big eye roll was involved when I read the passage.

Scenario: An elderly male dressed in sweats is found wandering the streets of New York in a confused state.

The author’s solution: The police take him to a nursing home.

Well, yea, just— no.

If police find an elderly male, let alone any confused individual, wandering the streets without any ID the first place that person is going is straight to the ER likely via ambulance.

The reason? One, is to make sure nothing medically is wrong. Chronic diseases such as dementia and Alzheimer’s are not the only reason the elderly people become confused. Something as simple as an electrolyte imbalance could be the cause. In any new onset confused state, other minor and major medical conditions need to be ruled out first. What might some of those be? Electrolyte imbalance. Brain Tumor. Stroke. Head Injury. Brain Bleed.

Secondly, there is not a nursing home in the United States that will take in an elderly person unknown to them without a medical evaluation first. Plus, do you know all that’s involved for nursing home admissions? A lot.

In this instance, if the patient is deemed to not have anything clearly medical (that could be fixed or treated) causing his confusion, then the hospital would involve the police and likely social services for placement.

But no drive by drop-offs at the nursing home.

Author Beware: Provider Scope of Practice (EMS)

Here I am, happily reading along one of my favorite mainstream suspense authors, when a glaring medical mistake takes me right out of the story. Bummer! Now I’m wondering how long it would have taken this well known author to make one phone call to determine if this situation was plausible or not.

The scenario: The hero in our story is injured but doesn’t want to be transported by EMS to the hospital. He’s got other important things to do– like catch a killer. Awesome. EMS has him sign a release form and he’s on his way BUT the EMS team has given him an oral dose of a narcotic and two to take in the future when the pain comes back.

Did you hear that? That was steam billowing out of my ears.

This is a very common mistake authors make— issues that deal with scope of practice. I’ve blogged about it several times. This post has links to several others that just deal with scope of practice.

In simple terms, scope of practice is what a health care provider can and cannot do. EVERY licensed health care provider (a nursing assistant, a nurse, an EMT, a paramedic, a physician, a physical therapist, a pharmacist) has a scope of practice that is governed by their licensing board– whoever that might be. These governing boards determine the rules of practice. If the licensee does something outside of these rules they can be brought up on disciplinary action and even potentially lose their license. Scope of practice rules can vary from state to state.

In short– it’s bad to operate outside your scope of practice.

For instance, this document gives a pretty detailed overview of the medical treatments different EMS professionals can do.

The first problem with the author’s scenario is that EMS professionals do not carry oral narcotics to give to patients. Only IV and those that can be administered nasally.

The second problem is that EMS professionals not only operate under scope of practice laws but also medical protocols which outline the things they can do in the field and under what conditions. In fact, here’s a whole document that lists the EMS protocols for one hospital in Colorado that would give a nice overview for what likely happens in the US. There will be differences state to state but you could reasonably generalize from this.

Essentially, a paramedic giving a patient (who is refusing medical treatment) three doses of an oral narcotic (which he doesn’t carry) is a serious violation of his scope of practice. Only a few medical roles can prescribe oral narcotics and dispensing oral narcotics is the role of a pharmacist.

Authors should take scope of practice as seriously as medical professionals do because though your book might be fiction– the public will take it as fact.

Murdering a Television Scene

The ABC drama, How to Get Away with Murder, is a series not for the faint of heart. The show centers around defense attorney Annalise Keating (great acting by Viola Davis by the way) and how murder victims keep popping up around her where she may or may not be involved.

The second season opens with an intense scene where Annalise has been shot in the chest and subsequent episodes deal with the events leading up to this one scene. Just who shot her and why did it happen?

Of course, this is a great time to do some medical analysis of her EMS rescue. What’s follows is a conversation between two medics who are taking her to the hospital.

Medic One: Starting a 16 Gauge IV. Lungs are clear. Need another blood set for a second IV and a BVM. Blood pressure 70/palp. Pulse is thready.

Medic Two: Feels tachycardic. I’m seeing some JVD. Might have to do a needle thoracostomy. Need to get ETT right away. Diminished respirations. Chest is clear. Equal breath sounds but respiratory effort decreasing.

Just what does all this medical mumbo jumbo mean and is it medically accurate? Well, kind of.

When dealing with a trauma patient, getting IV access is paramount. Usually two lines of a large bore gauge is necessary. A 16 Gauge is a large size. And working to get two lines in is accurate.

What does BP 70/palp mean? Likely, you’re used two seeing two numbers in regards to blood pressures. Something like 120/72. The top number is what’s referred to as your systolic number– or the pressure inside your arteries when your heart is contracting. The bottom number, or your diastolic number, is the pressure in your arteries when the heart is relaxing. To get both numbers, you have to be able to listen to the blood pressure by using a BP cuff and stethoscope at an artery point– usually at the antecubital space (the crook of your arm.) The first time you hear the heart beat– that’s the first number. The moment you can’t hear it anymore– that’s the bottom number.

In EMS, active resuscitation scenes are really loud and it’s hard to hear. There is  technique where you feel for the blood pressure but you only get one number– the systolic one. In this technique, you feel where the radial pulse is (at your wrist) and pump the cuff up until you can’t feel it anymore. As you let the air out of the BP cuff, you record the number where you first feel the pulse. In this case 70– which is low. But, that’s why there is only one number and the “palp” denotes it was felt or palpated.

Pulse being thready– means it feels thin and weak. Also appropriate for someone experiencing blood loss related to a gunshot wound. As does what the second medic begins to say– feels tachycardic which means the patient’s heart rate is increasing– which is also a sign of blood loss.

The main medical inaccuracy with this scene is the procedure one medic says they might need to do– a needle thoracostomy. Just what is that?

A needle thoracostomy is done to pull air from the chest that has caused a lung to deflate– here from a gunshot wound to the chest. It is a rescue measure– meaning it will buy you some time until the patient can get a chest tube placed in a hospital setting.

But note what the medics say over and over– her breath sounds are equal. These comments denote that her lungs are filling as they should. If one lung was “down” or deflated from the gunshot wound– the breath sounds should be unequal. Generally, you can’t hear breath sounds on the side of the chest where the lung is deflated– or there is very little air moving on that side.

The writer has also picked the wrong procedure. When one medic comments– “I’m seeing some JVD.”– this usually denotes an obstruction somewhere in the chest (like a deflated lung or blood collecting around the heart) and blood is having difficulty flowing as it should and so the blood is backing up into the veins. JVD= Jugular Venous Distention and is when the jugular vein is easily seen at the side of your neck because it is filling up with blood.

Since the medics state her breath sounds are “clear and equal” then we know the problem is not with her lungs but could be with her heart.

The rescue procedure for blood collecting around the heart is called “pericardiocentesis”.

Again, Hollywood, I am available for medical consultation. Let’s rescue our characters using the right procedures.

If you’re interested in seeing a video on needle decompression (the first) and/or pericardiocentesis (the second)– then watch the videos below. They aren’t gory.

Author Question: Hockey and Head Injuries


Elaine asks
:

A hockey player gets knocked down in a fight and hits his head (with his helmet in place) on the ice. Could he be unconscious? I know the trainer would come out on the ice and possibly a doctor, but if he is unconscious, I’m assuming they’d call for the stretcher and put him in the ambulance as a precaution.

I was going to have him regain consciousness in the ambulance on the way to the hospital, but wonder what would the paramedics/EMT (which/who would it be) be doing in the ambulance? What would they do if he “came to”? And what would happen when they reached the hospital?


Jordyn Says:

Yes, it would be possible for a hockey player to be knocked unconscious with a fall on the ice even with his helmet on. If he stays unconscious, then he’s going to need to be transported to a hospital. Baseline treatment would be C-spine precautions (C-collar, back board), supplemental oxygen even if he is breathing adequately on his own, and likely an IV.

If he wakes up in the ambulance, they’ll first orient him to what happened. “Hey Mike, my name’s Roy and I’m a paramedic taking care of you. You took quite a hit on the ice and you were knocked out. To be safe, we put a c-collar on you and put you on a backboard to protect your back. We’re on the way to Swedish Medical Center to get you checked out.”

Then they’ll assess him. Can he move everything? Can he feel everything? Does he know his middle name? Does he know the month? Does he remember any part of the accident? Does he know what city he’s in?

At the hosptial in the adult world– you’re more likely to get a CT of the head for this type of injury. So upon arrival to the ER– the nurse would check his vital signs, do a neuro exam (as described above), and make sure the IV is patent.

The doctor will likely order plain x-rays of his neck and spine and a CT of his head. If all that checks out– he would probably be discharged home.

Trauma Call/Domestic Violence: Dianna T. Benson, EMT

I am pleased to welcome back award-winning novelist Dianna T. Benson. I love how she writes these scenes fictionally but conveys a host of medical details along with it. 

Welcome back, Dianna!
EMS 6, Stabbing, TAC Channel 12”
     Responding to a domestic disturbance call, my partner and I park our ambulance in front of an upscale home over a million dollars. Not atypical – EMS is too often called out to the rich on domestic violence.
     “Did you know the power company turns off this zip code for lack of pay more than any other in the state?” I ask my new partner.
     “Yep. Idiots living beyond their means. No wonder they’re so stressed out and hurt each other.”
     At the front door, we join a fire crew, as three cops enter the house, all three with weapons drawn.
     “Scene isn’t safe?” I ask.
     “Not sure,” the last cop answers then trails his two buddies.
     The fire crew of four hangs back with me and my partner.  
     “Was the door unlocked?”
     “Yup,” one of the firefighters answers me.
     After five long and boring minutes of standing around on the lawn in the dark of night, I radio in to dispatch. “EMS 6. Standing by outside residence. Any updates from PD on scene?”
     “Yes. Scene is secure. PD is with victim.”
     “Copy that.” I roll the front of our loaded stretcher into the house.
     In the family room, I find one officer bent over a body, the other two talking with an agitated man.
     I kneel at the woman’s other side. She’s supine on the carpet, her lapped hands pressed to her lower abdomen and covered in blood.
     “Ma’am?” I touch her shoulder in comfort.
     My patient blinks at me then flutters her eyes closed.
     “Can you tell me your name?”
     “Judy,” she whispered in a pained voice.
     I brush my hand over hers. “Judy, are you hurt anywhere other than here?”
     “Don’t know,” she mumbles.
     “Judy?” I stare into her eyes, mascara smudged underneath them. “Can you move your arms down at your sides?”
     She does.
     My partner hands me trauma scissors, a stack of 5X9 sterile gauze pads, and an occlusive dressing. As I rip open the gauze packages, my partner hooks up the patient to our cardiac monitor and focuses on assessing and monitoring vital signs.  
     “How can I help?” one of the firefighters asks me.
     “Perform a rapid trauma assessment.”
     “You got it.” He starts at the head.
     With the trauma scissors, I cut Judy’s shirt, exposing the wound. Noting no debris other than blood, I cover the gushing horizontal wound—thin but long—with one sterile gauze pad after another, and apply direct pressure with my palms. “Did a knife do this, Judy?”
     “He did.”
     “With a knife?”
     “Steak knife.”
     “I see nothing else,” the firefighter informs me at the patient’s feet.
     I nod. “Thanks.”
     I glance at the monitor screen for Judy’s vital signs. Her heart rhythm is normal, but her blood pressure is too low, pulse too high, indicating she’s headed to shock due to blood loss. My guess is she’s bleeding internally, the knife blade sliced an organ or two, maybe the abdominal aorta. Regardless of what’s injury, she needs a surgical team.
     I look at my partner. “We gotta go. Now.” 
       
     “Give me the switchblade,” one of the cops says, alarm in his tone. “Sir, you’re just making things worse for yourself.”  
     “Past time to go,” I whisper to my partner, a rush of panic clogging my throat.
     “No kidding,” he whispers back, wide-eyed.
     “Get out of here,” one of the cops says to us.
     “What’d you say to them?” the agitated man shouts.
     “You don’t want a murder charge, do you? The EMS crew needs to get her to the hospital.”

     The cops deal with the perpetrator, as my partner readies the stretcher. I blanket the dozen or so bloody gauze pads with a towel.
     Inside the moving ambulance, I raise the foot of the stretcher to treat for shock. I cover Judy’s mouth and nose with a non-rebreather oxygen mask and turn on the O2 to 15 lpm. Since none of her organs eviscerated, I do not apply an occlusive dressing. Instead, I add additional 5X9s and a fresh towel and instruct the one firefighter who joined us en route to press his hands over it for direct pressure. I insert an IV saline bolus and consider administering morphine or fentanyl for pain.
  
     “More cops dispatched to scene,” my partner yells back from the driver’s seat. “Guy stabbed one of the cops and fled the scene on foot.”
     I look down at my patient. She doesn’t indicate she heard those disturbing words.
  
     “We’re ten minutes out,” my partner yells back at me.
     I pick up the radio. “Wake Med ED, this is EMS 6.”
     “Go ahead EMS 6.”
     “We are enroute with a thirty-eight year old female. Left lower quadrant adnominal stab wound. No evisceration. BP 82 over 56. Heart rate 173. Non-rebreather at 15 liters per minute. Legs elevated for shock treatment. Place OR on stand by. ETA 10 minutes.”
     “See you in 10. Wake Med out.”
     “EMS 6 out.”  
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Dianna Torscher Benson is a 2014 Selah Award Winner, a 2011 Genesis Winner, a 2011 Genesis double Semi-Finalist, a 2010 Daphne de Maurier Finalist, and a 2007 Golden Palm Finalist. In 2012, she signed a nine-book contract with Ellechor Publishing House. She’s the author of The Hidden Son, her debut novel. Final Trimester is her second release. After majoring in communications and a ten-year career as a travel agent, Dianna left the travel industry to earn her EMS degree. An EMT and a Haz-Mat and FEMA Operative since 2005, she loves the adrenaline rush of responding to medical emergencies and helping people in need. Dianna lives in North Carolina with her husband and their three children. You can connect with Dianna via her website.
 
   
          

Dianna T. Benson: A Son’s Tale of Traumatic Brain Injury


The term concussion is well known. The medical field refers to a concussion as a TBI – Traumatic Brain Injury. Contact sports are one of the top causes of a TBI, another are MVCs – Motor Vehicle Collisions.
My teenaged son has endured four concussions. The first two as a goalie for the Junior Hurricanes and the third in a MVC. The first one took him out of school for a month and hockey for three months. The second, a year later, was more mild, which is unusual. Typically, a patient suffers a more severe TBI the second time. In the MVC, a classmate was driving them to school when another car struck them. This third TBI ended my son’s hockey career, preventing him from attending the Junior Hockey draft in Canada Spring of 2013.
The problem wasn’t simply that this was his third concussion, although that in itself is a strong reason to end a contact sport career. With this third TBI, a neurologist evaluated him versus just the concussion clinic MDs who’d treated him with the first two. Not only was it his third TBI, but his symptoms were extremely severe, which didn’t make sense to me – the details of the MVC didn’t suggest such injuries for my son: 1) None of the others involved in the crash suffered any injuries 2) No air bags deployed 3) Vehicle damage was minor. As an EMT for nearly a decade, I wondered about underlining health conditions in my son. I also considered he had not fully recovered from the first two concussions and was in denial about his symptoms in order to play hockey.
Sure enough, the neurologist diagnosed my son with hyper-mobile joints (something I already knew but wasn’t aware of the danger with contact sports.) The MD also diagnosed him with mild CP (cerebral palsy), a diagnosis that made sense to me since my son was born in respiratory arrest and was non-verbal and had spasticity until over age two. Both diagnosis are a recipe for injury, especially in contact sports. The MD gently told my son he was done playing goalie forever – it was devastating and crushed him. Understanding his hockey career was over, he admitted he’d ignored symptoms because he had a shot to play Junior Hockey, college hockey, and possibly professional hockey. A life-long athletic competitor myself, I completely understood the denial that led him to ignore his body.
Hyper-mobile joints, while creating an incredibly athletic body, are highly susceptible to any musculoskeletal injury in that individual. For my son, after two TBIs in a contact sport, his hyper-mobile neck was easily and severely whip-lashed in the MVC, jostling his brain fiercely, causing all his concussion symptoms to return and more heightened than ever.
Ten months after the car accident, the fourth TBI occurred December 2013 just days after the neurologist cleared my son to return to his life minus contact sports. The neurologist gave my son the green light to snowboard. That December day on the mountain, my son didn’t even hit his head and he sustained no head trauma – simply snowboarding jostled his brain enough to cause another TBI.   
Even though he’s extremely athletic, my son’s body shouldn’t do what it can to do. The risk of permanent brain damage and partial or full paralysis is too high for him– something he now understands. I described it to him as this: When Cam Ward (the goalie for the NHL team Carolina Hurricanes) is playing goalie, his body is naturally like a SUV of protection in a MVC. Whereas, for my son, his body is like a motorcycle in a MVC – no protection.
Until Spring 2015, my son is restricted from doing anything with speed, wheels, height or repetition (basically everything fun.) This next year his brain will heal, then little by little he can attempt things (no contact sports ever, though) to see how his body responds. At 6’7” in height and extremely athletic, he appears a medically sound seventeen-year-old, but inside his body tells a different story. 

    

God works in amazing ways and this is my son’s blessing. Since cerebral palsy only affects motor function, and none of the four TBIs caused him any loss of cognitive abilities, he’s still as annoyingly brilliant as ever and is anxious to head off to college this fall. For now, his goal is to graduate medical school with a degree in neurology and become a neurosurgeon since he feels (understandably so) he can relate to patients’ symptoms with head trauma. 
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 Dianna Torscher Benson is a 2014 Selah Award Finalist (winners not yet announced), a 2011 Genesis Winner, a 2011 Genesis double Semi-Finalist, a 2010 Daphne de Maurier Finalist, and a 2007 Golden Palm Finalist. In 2012, she signed a nine-book contract with Ellechor Publishing House. She’s the author of The Hidden Son, her debut novel. Final Trimester is her second release.
After majoring in communications and a ten-year career as a travel agent, Dianna left the travel industry to earn her EMS degree. An EMT and a Haz-Mat and FEMA Operative since 2005, she loves the adrenaline rush of responding to medical emergencies and helping people in need.
Dianna lives in North Carolina with her husband and their three children. 
Her releases are available wherever books are sold. Below are the links to Final Trimester at the three largest booksellers: