Pediatric Medicine

The Good Doctor S1/E5: Lying to Kids is a Good Thing?

/ Jordyn Redwood / Leave a comment

When The Good Doctor starts messing with pediatric scenarios . . . well, I just cannot keep my mouth closed. You can see other posts I’ve done on The Good Doctor here, here, here, and here.

In this episode (spoiler alert!) Shaun is convinced that a pediatric patient, a boy around the age of fourteen, has been misdiagnosed with cancer. This patient first comes to the hospital for a bone fracture and Shaun goes in to consult. Shaun is over identifying with this patient because he looks just like his brother that died during his younger years.

Issue #1: A first year surgical resident consulting on an ortho case. There’s really no reason for Shaun to even be consulting on this case. An orthopedic resident, yes. If no orthopedic resident, then an ortho attending. But this is outside the realm for a general, first year surgery resident.

Issue #2: There is a tendency in these shows to separate parents from children during treatment. This is not really done or encouraged at all anymore unless the presence of the parents put the child at risk in some manner.

Issue #3: This child has had a cancer diagnosis for SEVEN months and his parents haven’t told him he has cancer. This is unconscionable. We don’t need to lie and hide the truth from children. They are so much stronger than we give them credit for! Also, this is highly unethical and would not be supported by any decent pediatric medical team. Great effort would be made to help the parents give their child this news.  It doesn’t benefit him or protect him to be told this lie. Plus, is he not receiving treatment? The episode proves this point when the patient tells Shaun he already knew he had cancer.

Issue #4: Because his parents haven’t told him, Shaun decides to without their permission. Again, we would work very hard to have the parents tell the child this news. It’s unethical for any healthcare provider to do this without the parents permission no matter what. So much would be done to help these parents talk to their son. I’ve never seen this happen in pediatrics . . . like ever.

Issue #5: In order to prove his alternative diagnosis, Shaun decides to perform a medical procedure on the patient without the parent’s consent. This is legally dicey and Shaun should suffer disciplinary repercussions for doing so.

Issue #6: A patient after having open heart surgery is in recovery with only an IV and simple monitoring. Any patient who has had open heart surgery will have a variety of tubes— like chest tubes. It’s not a simple recovery.

Are you watching The Good Doctor? What do you think of this surgical resident getting away with all these bad things without repercussions?

 

9-1-1 S1/E3: Evaluation and Treatment of Overdoses

/ Jordyn Redwood / Leave a comment

In Episode 3 of 9-1-1, the story opens with officer Athena Grant, played by Angela Bassett, finding her daughter unconscious from taking hydrocodone pills as seen in the trailer below. The daughter, who appears to be between twelve and fourteen, is whisked off to the hospital and admitted to the ICU in short order. One, did they treat this ingestion (or overdose) correctly? Two, would this type of ingestion warrant ICU admission?

It’s stated in the episode that the daughter took “six to seven” hydrocodone pills. Hydrocodone is a combination of acetaminophen (Tylenol) and a synthetic type of codeine. It comes in many different preparations with different amounts of acetaminophen and hydrocodone. Where do we start to evaluate whether or not the ingestion is worrisome?

1.  How is the patient? What signs and symptoms do they have?  The EMS crew in this situation is lucky. The mother knows exactly what the daughter took. She presents unresponsive with slow breathing. Number one treatment in this situation after assisting with her breathing? Give Narcan which this crew absolutely does not do. Narcan is a reversal agent for opioids. It can be given via a mist up the nose so you can generally reverse the sedative effects of the drug without even starting an IV. It is a life saving measure because it is the not breathing part that will kill you first. This is the medication they should have given first.

In absence of knowing exactly what the patient took, we can look at clusters of signs and symptoms called toxidromes which might point us in the right direction.

2. What did the patient take? When did they take it? How much did they take? Many drugs have multiple components and we have to evaluate EACH component and whether or not this could prove harmful to the patient. The opioid  (once reversed with Narcan) is probably the least concerning. The amount of acetaminophen ingested is our next priority and we would calculate how many milligrams per kilogram she took. We know for acetaminophen that when you start to get between 100-150mg/kg that there could be a potential for liver damage. There is a reversal drug for acetaminophen’s damaging effects on the liver called Mucomyst, but there is a window in which this can be given to be effective. Usually, a poison control center will help us manage these types of patients.

In this case, let’s say she took six pills of Lortab 7.5/500. From this we know that each pill has 500mg of acetaminophen. Assuming the average 12-14 y/o is about 100 lbs (converted to 45 kg) then she took about 66mg/kg of acetaminophen. A four hour Tylenol level (measured four hours after the ingestion) would be checked to ensure she wasn’t toxic, but in this case likely not.

3. Will this patient be admitted to the ICU? It might come as a surprise, but ingestions of medications are most often not admitted to the ICU. Most are managed and observed in the ER. In this case, the girl should have been given Narcan by EMS. We would continue to watch for the somnolent effects of the opioid and evaluate the risk of the acetaminophen.

Also, it’s generally protocol that an aspirin level is measured as well even if the patient denies taking any. We can’t always depend on the patient being truthful about what they took and aspirin can have very devastating effects as well. Other labs depend on the medication ingested and what parts of the body if affects. This patient would likely not be admitted to the ICU.

Also, if we get a toxic ingestion within an hour we can give activated charcoal (that literally looks like black sludge) that will bind the medication. This is not always done for several reasons. One is the risk of the charcoal ending up in a patient’s lungs during administration. Usually this is done under the recommendation of Poison Control.

4. Do we notify Child Protective Services? In this episode, Child Protective Services conducts a mental health exam on the teen. In the real world, this evaluation takes place through mental health providers not associated with the state. State involvement is generally reserved for what we would consider a risky home environment. A teen getting into their parents medicine cabinet for some pills would not fall into that category. What would? A two-year-old ingesting crack cocaine that was lying around the home. Each case is handled very individually, but this case presented in 9-1-1 would not rise to that level in my opinion.

As a side note, parents are not separated from their children during medical treatment. Can we please stop perpetuating this myth?

What do you think of 9-1-1?

Top Three Pet Peeves of Pediatric ER Nurses

/ Jordyn Redwood / Leave a comment

At least my top three!

This week, I’m highlighting some blog posts that I did for Erin MacPherson’s Christian Mama’s Guide last year. Some of you may not know but I am a real live pediatric ER RN. As always, these posts are meant to be educational and do not replace a doctor’s visit if your child is ill.

Erin has a WICKED sense of humor and is releasing a series of books this spring so I hope you’ll keep an eye out for them.

Here’s a look into the mind of the pediatric ER nurse. Don’t we all have pet peeves when it comes to our jobs? Of course… the ER nurse is no different. Often times, these are not mentioned in “public” as we don’t want to offend families. But, in honesty, there are some things parents do that drive us crazy. Here are a few at the top of my list.

  1. Calling medicine candy. This is a big no-no for us pediatric nurses. We really don’t want kids to associate taking medicine with the fun of having candy. Candy is good. Candy is fun. Candy is generally not lethal if you eat too much. Medicine is far different from that. So say something like, “This tastes sweet.” Or “This tastes like orange.”— but don’t associate medicine with candy in the same sentence.
  2.  Children not wearing helmets. I’m amazed at how many families come to the ER over concern for head injury after a fall off of (insert something with wheels here) and their child wasn’t wearing a helmet. First question: Do they have one? Often times the response is, “Yes, I just can’t get him to wear it.”
First off, as a parent, set the example. Are you wearing your helmet when you ride your bike? Second, from the moment your child is on anything with wheels, they need a helmet. Yes, even when they’re on their tricycle. This will institute a habit and an expectation—just like wearing a seatbelt.

Secondly, be firm. If they don’t wear their helmet, they lose their wheels. Parent, “I can’t keep him off his bike.” Well, then the wheels come off the bike. The skateboard is locked in the trunk of your car. Be firm.
It only takes one bad head injury for devastating effects. Don’t risk it.
  1. Smoking. Secondary smoke is a big health risk for kids. If you smoke, you need to stop. Smoking outside, unfortunately, doesn’t help. Yes, even if you have a “smoking jacket”. If I can smell smoke, the particles are on you and can even be enough to trigger an asthma attack in kids. If you are a smoker, talk to your pediatrician about resources your state might have to help you quit. Smoking during pregnancy has been linked to the development of congenital heart defects in infants along with a host of other problems.
Now, you tell me, what are some other pet peeves you think a pediatric ER nurse may have? Are you offended by reading these?


Dianna Benson: EMS Treatment of a Minor (1/2)

/ Jordyn Redwood / Leave a comment
Mart asks: My MC is 16 yrs old. She gets hit by a truck. She has road rash. Right leg turned black and blue. Shin welled up. But other than feeling like she literally was hit by a truck, she is okay….she thinks. What would most likely occur after an incident like this? In short, how can I make it so a 16 yr old girl who has been hit by a car, stalls at home before her Mom takes her to the ER?
I hope there is a way.
Dianna says:
A 16-year-old can accept EMS treatment and transport to a hospital. However, a 16-year-old cannot refuse treatment and/or transport – EMS has a refusal form that requires a signature from the patient, a minimum of age 18, or from a parent or legal guardian of a minor aged patient, 17-years-old or younger. EMS will not leave a patient at the scene until we obtain a signed refusal form (we wait for as long as it takes to obtain that signature).
It’s not uncommon for patients to refuse an ambulance transport to avoid additional medical bills and then have someone drive them to the ED.
From your scene description, it sounds like the patient was a pedestrian stuck from a truck at low speed, propelling her body in the air slightly; her leg skidded on the road, stopping her.
A pedestrian struck by a moving vehicle is a serious mechanism of injury thus a high priority trauma. EMS will encourage both treatment and transport by explaining to your patient she may have internal injuries.
I actually say to patients, “I don’t have x-ray vision or CT scan capabilities inside my ambulance, so I’m unable to verify if you’ve sustained internal injuries or not.” If transport is still declined, I obtain a signature of refusal from a parent or legal guardian (the uncle wouldn’t be enough). The way around this legal issue is for the MC to call her mom and EMS waits for her to arrive on scene.
Was the truck driver at fault for hitting the MC? If the driver is legally at fault, then most patients tend to accept EMS treatment and transport (think law suit). Regardless of any pending law suit, I think the uncle would insist the main character be transported.
Once the mom arrives on scene, I find it unbelievable (and not likeable or smart of the mom) that a mom would refuse transport to a hospital for their injured teenager struck by a moving truck as a pedestrian. That’s a serious mechanism of injury (most car accidents are minor, but being hit by a car as a pedestrian is serious). However, if you prefer to avoid an ambulance ride in your story, then write in the following: 1) Keep the injuries extremely minor – EMS finds no abnormalities beyond right lower extremity minor swelling and abrasions with slight oozing blood.  2) All her vital signs are within normal limits. 3) The patient assessment from EMS cleared C-spine immobilization (backboard and neck collar).
However, since the mechanism of injury is significant, in order for those three above points to be believable, you’ll need to write in the following: 1) The truck was moving at extreme low speed (like 5 miles per hour); it’s amazing how much damage just 10 miles per hour causes. 2) The truck is small or it’s a small car. 3) She wasn’t thrown far in the air (height or distance) and didn’t hit anything else. 3) Her behavior and signs and symptoms indicate she suffered no injuries beyond minor contusions and abrasions. 4) She’s adamant against a trip to the ED.
***********************************************************************

After majoring in communications and enjoying a successful career as a travel agent, Dianna Torscher Benson left the travel industry to write novels and earn her EMS degree. An EMT and Haz-Mat Operative in Wake County, NC, Dianna loves the adrenaline rush of responding to medical emergencies and helping people in need, often in their darkest time in life. Her suspense novels about characters who are ordinary people thrown into tremendous circumstances, provide readers with a similar kind of rush. Married to her best friend, Leo, she met her husband when they walked down the aisle as a bridesmaid and groomsmen at a wedding when she was eleven and he was thirteen. They live in North Carolina with their three children. Visit her website at http://www.diannatbenson.com