New Amsterdam: Prioritizing Epinephrine Over Oxygen

New Amsterdam is a new medical drama on NBC this year. You can see my first post about it here. Today, I wanted to review a medical scenario with you and the problems with they way it’s presented.

As I discuss the scenario remember that all medical providers are taught this from the very moment they step into medicine: A, B, C— Airway, Breathing, Circulation.

Here’s the setup: A man travels from Liberia where he begins to exhibit signs of Ebola. They place him in isolation (a good move). A big lecture is given by Dr. Max Goodwin, the new medical director, that no one is EVER to enter the isolation room without the proper PPE (Personal Protective Equipment). From there, it gets a little bit strange.

The first issue is that it’s stated that the isolation room is “stocked with every available medication should the patient need to self medicate.” A few problems. A sick and deteriorating patient is going to have the wherewithal to find a drug and give it to himself? This is later proven to be a bad idea when the patient can’t even reach for an easily accessible oxygen mask without falling out of bad.

Also, everything in the isolation room is going to get thrown out and likely charged to the patient so for a medical director who is so concerned about minimizing costs for the patient . . . well, you can see where I’m going with this.

The patient begins to cough up blood, bleeding profusely from his mouth, and has difficulty breathing. As the doctor is getting into her PPE, she instructs him to give himself oxygen which he is unable to do and then falls out of bad. Without getting into full PPE, she enters the room to help.

I actually like this aspect of the show. As I’ve said all along, medical people can make bad choices, as long as the writer shows repercussions for them which they do in the show.

The doctor immediately begins to work to aid his breathing. This is the right choice. She believes the airway is too obstructed so she immediately moves to a needle cricothyrotomy. This is generally done as a rescue measure when other attempts to secure an airway have failed— it is not the first choice.

However, as the doctor inside the isolation room is generally doing most of the right things, Dr. Goodwin (the new medical director) is telling her to give the patient an IV dose of Epinephrine before she gives him oxygen. He tells her to prioritize the epinephrine over the oxygen. At the screen shot to the right, what’s obvious is that the blood pressure (82/40) is low and that the patient’s oxygen levels are REALLY low at 64% (normal is generally considered above 90%).

There really isn’t an indication for epi IV (as in a code dose) in this scenario. The first two reasonable thoughts for this patient’s low blood pressure are sepsis (low blood pressure caused by overwhelming infection) and blood loss from the obvious hemorrhage. Epi can be given in this situation (for low blood pressure related to sepsis) as a continuous drip, but not as a push medication.

Most importantly in this situation, epi would not be prioritized over the patient’s alarmingly low oxygen levels.

The Lyme Wars: Part 2/2

Today, I’m concluding my interview with author Brandilyn Collins. You can find Part 1 here. Today, we focus on healing and what medical professionals can do to improve the care for those affected by chronic illness.

Jordyn: You’ve been open about God healing you during your first Lyme infection. Did your feelings/attitude toward God change when you were reinfected? Are some of these attitudes reflected in Janessa’s attitude toward God as displayed in the novel?

Brandilyn: When I was reinfected with Lyme in 2009, I couldn’t believe it! I gave God a hard talking-to. What are you doing? We’ve been here, done this. And aren’t you worried about your reputation—so many people know you cured me once? What if they doubt you now?

Well first, God informed me that He’d been dealing with the reputation thing since He brought the Israelites out of Egypt, so thank you very much, but He had that under control. Second, I can see now in hindsight that if I hadn’t experienced round number two of Lyme, I wouldn’t have written Over the Edge. As it turned out, six months of antibiotics cured me of that round.

Regarding Janessa, her spiritual journey is similar to mine. When I had Lyme the first time, I learned how to pray the psalms, both as petition and in praise—whether I felt like praising God or not. Most of the time I didn’t. It was a wonderful lesson that has changed me to this day.

Jordyn: Any words of wisdom for doctors/nurses in dealing with patients who have chronic pain/illness?

Brandilyn: Please, please don’t tell them it’s “all in their head” or some form thereof. Just because you can’t diagnose an illness—that doesn’t mean the patient simply wants attention or is a hypochondriac. It’s bad enough facing chronic illness. Worse still to be invalidated by the medical community. And please—educate yourself about Lyme. Admittedly, this is hard to do, because typical education would be in the form of reading published articles in esteemed medical journals. Unfortunately, these articles are based on the old, wrong assumptions about Lyme (or the authors simply ignore other research altogether). Google “lyme wars” to start online research. And—I have to get in that plug—read Over the Edge. It will alert you to the symptoms and issues involved in the Lyme wars—and how those wars came about.

Secondly, I want to talk to you doctors/nurses who do know about Lyme but are afraid to diagnose it. I understand your dilemma. I understand you don’t want to get into a battle between treating a patient long-term as he or she needs and your medical board. The political climate for you regarding Lyme is very bad. But please don’t send that patient away, saying, “I don’t know what’s wrong with you.” At least admit to the patient that he may have Lyme and refer him to an organization that can help find a Lyme doctor. (Googling “find a Lyme literate doctor” is easy.)

Leaving a possible Lyme patient completely in the dark opens him up to extended, further debilitating disease—if he does indeed have Lyme. I’ve seen this happen. I’ve seen Lyme patients lose all quality of life and become bedridden because their doctors didn’t want to admit Lyme, even when those doctors recognized the signs. I’ve even seen doctors refuse to test for Lyme when the patient requested it.

Jordyn: Any final thoughts?

Brandilyn: Good health and blessings to all. ~ Brandilyn

Thank you so much, Brandilyn, for your time. Blessings to you in your writing and to the continued success of Over the Edge.

Even in writing fiction, it’s a must to be factual for the story to ring true. Brandilyn also started a web-site for Lyme patients to discuss their experiences as well as some additional education regarding Lyme disease. These are great resources for research.

Blog Note: This interview with Brandilyn was originally published in May, 2011. Still, there appears to be confusion on how to deal with these patients as evidenced by just one recently published news piece called Defining Lyme: Medical community struggles with treatment.

Do you know anyone who suffers from chronic Lyme disease? Have you ever incorporated a disease into a story line?

Help spread the word about Brandilyn’s interview and Lyme Disease!

Brandilyn Collins’ insight into Lyme Disease: Part 1/2. Click to Tweet.
Brandilyn Collins’ insight into Lyme Disease: Part 2/2. Click to Tweet.

 

The Lyme Wars: Part 1/2

Since May was Lyme Disease Awareness month and we’re getting into tick season with everyone enjoying the outdoors, I thought it would be great to repost Brandilyn Collins’ thoughts on the topic. You can check out all of Brandilyn’s amazing books by vising her website. Part two of her interview can be round by following this link.

What do you do if your a novelist, infected with a potentially life-threatening illness (twice) and there are two camps of medical thought as to the diagnosis, seriousness and treatment of that illness?

How about . . . write a suspense novel.

This is the situation that best-selling author Brandilyn Collins found herself in. Over the Edge is a novel based on her real life experience of battling the medical community in their current thought process concerning Lyme Disease. I have to confess, I learned a lot about Lyme while reading this engrossing suspense tale.

I’m honored to have had the chance to interview Brandilyn for her thoughts on Lyme Disease.

Welcome to Redwood’s Medical Edge, Brandilyn!

Jordyn: I was told once by an editor with a well-known publishing house that “issue-based novels don’t sell well.” Does this thinking concern you especially when writing this novel under a new publisher?
Brandilyn: First, thanks very much for our discussion today. I appreciate the opportunity.
As to your question—I never even considered it. A couple thoughts: One, it’s important that the novel first and foremost be about entertainment, not informing. If the author fails to keep readers turning pages, those readers will stop reading—and never “hear” the message. So when I sat down to write Over the Edge, topmost in my mind was meeting the four-point promise of my Seatbelt Suspense® brand: fast-paced, character-driven suspense with myriad twists and an interwoven thread of faith. Two, once I’ve met my brand promise in Over the Edge, I then have thousands of potential new readers—those in the Lyme community, who will feel validated by the story. So in that case, an issue-based novel only helps in marketing. Further, I’m passionate about the subject, which can only help as I interview in various venues.
Jordyn: Redwood’s Medical Edge focuses on dispelling medical myths that are commonly perpetuated in writing. What do you consider to be the three most popular myths among the lay public concerning Lyme disease? Among medical professionals?

Brandilyn: Great question!

Among medical professionals:

1.  That Lyme disease can always be cured by a two to four week round of antibiotics. In truth, chronic Lyme can take months, even years, to treat with antibiotics.

2. That a patient must display the bulls-eye rash to have Lyme. Many patients never have the rash. Others may have a rash, but it doesn’t look like a bulls-eye.

3. That a negative test result means a patient doesn’t have Lyme. The CDC (Centers for Disease Control) says on its web site that Lyme is a clinical diagnosis, meaning that the entire presentation of the patient is taken into account. In addition, tests for Lyme are notoriously unreliable, partly due to faulty criteria for certain tests, and partly due to the nature of the Borrelia (the bacteria that cause Lyme). Borrelia are a very formidable foe. They can hide from the body’s immune system by changing their outer protein coat, for instance. Since tests look for antibodies to the Borrelia, not the bacteria themselves, a true Lyme patient can test negative. Therefore symptoms of a patient can mean more to the Lyme-literate doctor than test results.

Myths among the lay public:

1. That doctors in general, or even specialists like Infectious Disease Specialists, know how to properly test and diagnose Lyme. Wrong—reference above.

2. That Lyme isn’t very widespread. In reality, the CDC has verified Lyme in all 50 states. What’s more, the cases of Lyme reported to and verified by the CDC is estimated to be only one-tenth of the actual number of cases.

3. That you’ll always know if you’ve been bitten by a tick. Nope. Many Lyme patients never knew they were bitten. The most likely stage for a Lyme-infested tick to transmit is during its nymph stage, in which it’s no bigger than the head of a pin. Very hard to spot on a body, especially after it’s half submerged under the skin.

Jordyn: You list several recommendations in the Author’s Note section to improve care for Lyme patients. If you could pick one for nationwide implementation, which do you think would have the most beneficial effect?
Brandilyn: The first step, even before redefining treatment, is to create better testing. Too many patients test negative for Lyme under the CDC criteria, then take years before they find a Lyme-literate doctor to administer more accurate tests, which show positive. Meanwhile, the Borrelia have had time to spread throughout the body systems and burrow deep into body tissue, where they’re hard to eradicate. Lyme patients, therefore, face a double whammy. They’re first told they don’t have Lyme—when, if they’d been allowed to catch the disease early, it in fact is treatable with two to four weeks of antibiotics. Then when they’re finally diagnosed months to years later—when the disease will now take long-term antibiotics—they’re denied the long-term treatment.
Jordyn: Are you a proponent of a Lyme vaccine?

Brandilyn: The first Lyme vaccine was a major disaster and was soon pulled off the market. Of course I’d be in favor of a vaccine that really worked. But the medical profession has such a hard time even defining Lyme. It was defined far too narrowly the first time around and is still being too narrowly defined. Hard to create an effective vaccine under those conditions. However, researchers continue to work on it.

We’ll continue this two-part interview on Thursday. What’s your Lyme IQ? Also, for your education, here is a helpful slide slow regarding Lyme Disease. These were interesting to me after reading Brandilyn’s book as some of the myths she is trying to expose are perpetuated in these clips. Can you find what they are?

Brandilyn Collins’ insight into Lyme Disease: Part 1/2. Click to Tweet.

*Originally posted May, 2011.*

Facing Darkness: Fighting Ebola in Liberia Part 2/2

Recently, I viewed the movie Facing Darkness produced by Samaritan’s purse highlighting their response to the Ebola outbreak in Liberia. I highly recommend seeing this movie. It is having an encore event in limited theaters on April 10th, 2017. Click this link for showings near you.

You can view Part I here that takes a medical view on how Ebola spread so easily and quickly through Liberia.

This post, I’ll be discussing some of the spiritual aspects of the movie. As a Christian myself, it was hard not to be amazed at some of the incidents (or miracles) that I’ll talk about here.

Samaritan’s Purse is a Christian organization run by Franklin Graham, the eldest son of famed evangelist Billy Graham. Samaritan’s Purse had a presence in Liberia before the Ebola outbreak. The American physician, Kent Brantly, was serving there as a missionary with his family at the onset of the outbreak.

When Ebola hit the region, there were only two organizations that responded despite the Liberian government’s cry for help. They were Samaritan’s Purse and Doctors Without Borders. Since Samaritan’s Purse already had a presence in Liberia, they were asked by DWB to respond to the Ebola crisis.

They agreed but had no training to do so, but they did begin to respond by caring for the sick and dying.

Dr. Kent Brantly eventually headed up the Ebola response in Liberia. He and nurse, Nancy Writebol, worked closely together. Nancy was mainly in charge of getting medical personnel in their protective gear before entering the hospital. To this day, it is not exactly clear how Kent or Nancy were infected with Ebola.

Many Christians believe there is a battle in the spiritual realm between good and evil. That these forces are at play on earth even if we don’t physically perceive them. When the movie Facing Darkness opens, they comment on a feeling of oppression in the area. “The sea had never seemed so angry.” There was an unrelenting rain that few had seen in many years. The country was still shrouded in the darkness of two civil wars.

I believe there are miracles still happening today. These are some of the things I consider miracles from Facing Darkness. There are spoilers here so stop reading if you plan on seeing the movie.

1. Kent Brantly contracted Ebola within days of his wife and children leaving Liberia for a wedding in Texas. This event likely saved them from contracting the disease.

2. ZMapp was used for the first time in humans— and it worked. ZMapp is a drug that is used specifically to treat Ebola. Up until that point, it had never been used in humans, only in monkeys.

3. Dr. Brantly was going to be life-flighted out of Liberia, but the plane broke down and had to return to the US. This event likely saved his life. At the time the flight started, Kent was feeling pretty well and deferred the first dose of ZMapp to nurse Writebol. However, as she was literally warming up the medication under her arm for administration, Kent’s health took a dramatic turn for the worse and they took the drug away from Writebol to administer to Brantly. If he’d been on that flight, he likely would have died.

4. Brantly’s survival and testimony as to what was happening in Liberia finally garnered some international support that enabled Samaritan’s purse to turn the tide via education to combat the spread of Ebola. The movie is pretty clear on how little the world provided aid during the Ebola crisis. Doctors Without Borders and Samaritan’s Purse were the only two organizations combating the disease and they were drowning. Their personnel were way overextended and they didn’t have the supplies they needed. Only the media attention after Brantly’s US return pushed the issue where finally financial support and supplies were offered.

Sometimes, it’s hard to understand God’s view when you’re in the middle of a crisis. Brantly’s infection was one of the worst things that happened in his life, but it also ended up saving a country.

Many people featured in the film continue to serve the people of Liberia.

So many lessons in this one film— medically and spiritually. Please, go see it.

Facing Darkness: Fighting Ebola in Liberia Part 1/2

On May 30th, I attended a limited showing of the movie Facing Darkness which is a documentary produced by the Christian organization Samaritian’s Purse about how they assisted with the Ebola crisis in Liberia. It is a fascinating piece of film and I highly encourage all to go and see it. There will be more showings on April 10th so check your local theaters for viewings. Honestly, I cannot recommend this movie enough.

What’s interesting as a nurse medically is why did Ebola take such hold in Liberia? What factors contributed to it being so widespread? What was the tipping point as they say— or those circumstances that when combined cause something to take on a life of its own.

There were several factors that aided the spread of Ebola in Liberia and I’ll discuss a few here. I often hear people say that widespread disease and outbreaks couldn’t possibly happen in the US— that our medical system could easily handle the onslaught of victims and prevent the spread quickly. I am not so convinced. After events like Katrina it’s easy to see how any local healthcare system could be overwhelmed.

Here are some factors that aided the spread of Ebola in Liberia.

1.  Liberia’s infrastructure was devastated by civil war. Liberia had been rocked by two civil wars. One lasting from 1989-1996 and the other lasting from 1999-2003. Because of the wars, much of their infrastructure, including healthcare, was limited. The Ebola outbreak in Liberia started in March, 2014. It would seem that a decade would be long enough for a nation to recover, but think about how long it took to rebuild Ground Zero after the 9/11 attacks. Liberia is an economically depressed emerging nation. It’s in the top ten of poorest countries. Before the outbreak, 4 million people were being cared for by fifty physicians (yes, 5-0.) 

2. Cultural practices spread the disease easily. Liberians have a very affectionate culture. Ebola is spread by direct contact with an infected person. Culturally, Liberians prolong touch via handshakes and hugging. Also, their care of the dead includes direct handling and washing of the body. In some instances, the bath water used to bathe the deceased family member is drunk. If a person dies from Ebola, their corpse is teaming with virus and these practices will infect family members.

3. People lived in close proximity to one another.  Ebola in Liberia was both an urban and rural issue. When the disease hit urban centers, its spread happened much more quickly.

4. Liberians didn’t believe Ebola was real. Early in the outbreak, people believed Ebola was merely a myth. That it didn’t exist.

5. There was distrust of the medical profession. As the Ebola outbreak became more prolonged, many Liberians began to believe that medical people were proactively spreading the disease instead of trying to stop it. They wouldn’t bring sick family members to the hospital which led to more infection. In fact, medical professionals were physically attacked in some instances because of this belief.

The Atlantic did a follow-up piece on Ebola in Liberia in its July/August 2016 issue. If you think Ebola cannot happen again to such a degree, where 11,000 Liberians were infected, think again.

As the article highlights, several factors that added to the outbreak are still present.

1. People still eat bushmeat. Bushmeat is a concern as an origin for Ebola infecting humans.

2. There remains little understanding among the Liberian population of how Ebola is spread.

3. There have been three small outbreaks since Liberia was declared Ebola free in May, 2015.

4. It is possible that Ebola could spread via sexual transmission months after victims are symptoms free.

5. The poverty is worse.

I highly recommend viewing Facing Darkness on April 10, 2017. It is an eye-opening experience.

Author Question: Medical Complications for Badly Broken Leg 1/2

Mareike Asks:

Greetings from Germany!

The character in question has several injuries, the most important of which is a severely broken leg (I’m talking cast all the way up to the hip). He got these injuries by being attacked and beaten up.

knee-1406964_1920I’m thinking open or compound fracture because then I can have him develop a bone infection. What I’m wondering is the order of things and how long it would take to develop what and how to recover, how long it takes, and so on.

I want him to either develop compartment syndrome and/or the above mentioned bone infection. From my understanding of the sources I’ve read, an infection can result from the treatment of the compartment syndrome, but not vice versa, so it would make sense to have that order, right? Those two are the main life/health threatening complications I could find while researching.

My ultimate goal is to write a story of recovery. Of the hardship, the struggle and pain, the setbacks. The physical therapy, the fear of whether or not he can go back to his old job.

Any resources you could point me towards when it comes to recovering from a very nasty break that might or might not require amputation or might lead to a disability would be greatly appreciated.

Jordyn Says:

Greetings from the USA! I’m going to give some thoughts on your question. I also consulted with a physical therapist since a large portion of your question deals with recovery and we rarely know what happens to patients in the long run.

I’ll give Tim’s thoughts on PT next post.

One thing I want to make clear is that treatment in the US is going to differ from medical treatment in Germany. If your novel is specific to Germany, then you really should run these thoughts by a medical person in your country. Some things should be similar, but some may also vary widely (like treatment of the actual fracture— use of fixators versus casting, etc.)

My first thought is it is really hard to get an open fracture of the leg from a beating. It’s not impossible, for sure, but we normally see injuries like this from mechanisms with a lot of velocity behind them— car accidents would be one example. So, sadly for your character, for this to ring medically true, I would probably add a weapon of some sort— like a metal pipe. And it’s more likely from repeated hits than just “one lucky” one.

The other thing is to understand the difference between compartment syndrome and the bone infection you mention which is called osteomyelitis. Compartment syndrome is a condition of swelling leading to a lack of blood supply. When you injure your body, it responds by swelling. Think of a sprained ankle.

Sometimes, this swelling can become so severe that is compresses on the blood vessels inside the extremity and either diminishes blood flow or cuts it off completely. This can be from just the injury, a cast or splint that is applied too tightly, or swelling after a cast was placed correctly.

Things begin to die when they don’t have blood supply. To alleviate the pressure, a fasciotomy is often done, which is a long cut through the skin and underlying tissue. It is a deep cut. If you Google pictures of a fasciotomy you’ll quickly get the idea. Not for the faint of heart. After this type of procedure, you have an open wound. Open wounds are always at risk for infection, but it doesn’t necessarily mean the bone would get infected.

Osteomyelitis is an infection of the bone. An open fracture (where the bone punches through the skin) can place a patient at risk for this type of infection. The dirtier the wound the more apt for infection. Wound infection does not develop immediately. Usually it takes 48-72 hours (24 hr at a minimum). Antibiotic therapy for osteomyelitis is extensive lasting 4-6 weeks. You can read an overview here.

Also, here is a link that deals with treatment of compartment syndrome.

With these injuries, coupled with the  added complications of compartment syndrome, fasciotomy, and/or osteomyelitis (or some other infection), your character is looking at 2-4 weeks in the hospital. He would likely go home on oral antibiotic therapy for his bone infection.

He’ll also need extensive rehab which Tim will highlight next post.

Author Question: Brain Infection

Dale Asks:

I have a character who ends up in a coma for three days. The character suffers from viral encephalitis which is brought on from huge amounts of stress, and I only have a little bit of info about this. I got the idea from a real life FBI profiler who went through this, but he only went into a few paragraphs of what it was like. I was wondering if you had any info about how someone would be cared for in this condition from the time of admittance to the time of release?

Jordyn Says:

brain-cellsTo start, let’s deal with what viral encephalitis is. Encephalitis is inflammation of the brain and/or spinal cord. Viral encephalitis means the infection is caused by a virus. When this type of patient presents to the ER, it may be hard to differentiate between encephalitis and meningitis. Symptoms of both encephalitis and meningitis can be fever, photophobia (sensitivity to light), headache, stiff neck, pain upon moving the neck, nausea and vomiting, and seizures. There are other symptoms as well. This is the short list.

One thing that struck me about your question is the stress aspect and why it made this FBI agent vulnerable. Stress weakens your immune system but wouldn’t be the cause of the encephalitis. There needs to be a causative agent (like a virus or bacteria) but he was likely set up to be more vulnerable by the stress he was under.

In the ER, we’ll draw blood to see if the patient’s white count and inflammatory markers are elevated. He may get a CT of the head. We absolutely will have to get a sample of spinal fluid through a lumbar puncture. Typically we have to collect a sample of the cerebrospinal fluid for testing before we give any antibiotics or antiviral therapy. Depending on the patient’s condition, it would be determined if they need admission onto a regular floor or the ICU.

If the cause of the brain infection is of a viral nature, the medical team will likely give symptomatic support as antibiotics are ineffective against viruses. There are anti-viral agents available, but this is up to the discretion of the medical team as to whether or not their use would be beneficial for the patient.

Symptomatic support in this case would be keeping the patient hydrated, controlling pain, and frequent reassessment of his neurological status.

For more information on encephalitis check out these articles here and here.