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

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

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?

Are Kids Just Small Adults?

I started in adult nursing. For three years, I worked adult ICU and a community centered ED which primarily saw adult patients with a few kids mixed in.

I thought I knew everything I needed to know about treating pediatric patients. Needless to say, my eyes were opened when I took a class called Pediatric Advanced Life Support (PALS). That was just a taste of discovering I knew very little about the uniqueness of a pediatric patient.

During my time in the adult world, I discovered my joy of working with kids. In fact, I would bargain with my co-workers to take all of their patients eighteen-years-old and younger if they took everyone over the age of seventy-five. Surprisingly, this was an easy trade and I began to learn most adult centered nurses were very uncomfortable working with a child– particularly a young child.

Then, an epiphany happened. There are places . . . whole big hospitals . . . where there are only kids. I need to go there. That began my career in pediatric nursing and I’ve never regretted choosing kids over adults.

What irks me about some of my adult counterparts is that they’re very unwilling to admit that pediatric hospitals are the best places for kids to go. They think they can do it the same or better. Trust me, I’ll be the first to admit that if you have crushing chest pain, I can do the basics to save your life, but I’ll also be the first one to drag you by the shoulders across the threshold to the adult ED because I know you’ll fair better there.

Why? Because they do adults every day and you get very good at what you practice.

I found this article very interesting. Confessions of a Preemie: How I Am Different than a Full-Term Baby. Isn’t that amazing to think about? The difference four months can make in development?

In a humorous way . . . it got me thinking about things pediatric nurses have to consider that would be very odd for an adult ER nurse to have to think of or deal with.

1. When stripping for the scale— kids are handing off favored stuffed animals, blankets and toy cars.
2.  The size difference. We have at least eight different sizes of BP cuffs (probably more when you get into preemie sizes.) In fact, we have multiple sizes of everything where as an adult focused ED might have a very small supply of pediatric equipment.
3. Vital signs are different according to age group. A newborn’s resting heart rate can be 160 where as this would be considered abnormal for a teen. We have to memorize a large range of “normal” vital signs for about five different age groups. The only vital signs consistent across age groups is temperature and oxygen level. Heart rate, respiratory rate, and BP all change with age.
4. Does your child suck their thumb? If so, which one? Hopefully, my adult counterparts are not asking this question (and if they are, maybe adding a psych consult) but in pediatrics, it’s very important when it comes to IV placement. We don’t want to put an IV in the hand that contains their favorite thumb for soothing. Ultimately, everyone gets cranky because the child will be cranky.

That’s just a very small sampling of some of the things that pediatric nurses have to deal with every day. Do you think you could do pediatric nursing?

Author Question: Disease for Infant

My good friend, Candace Calvert, drops by today with a medical question. Even though she is a former ER nurse extraordinaire– pediatrics was not her specialty so she is doing what medical people do best– consult an expert and I am happy to help out with the help of one of my physicians.

Candace writes inspirational romance with a medical backdrop. I happily endorsed, Rescue Team, releasing May 1st which is book #2 in the Grace Medical Series. Hope you’ll check out all of her books. She is one talented lady.

Candace Asks:

I need a disease/disorder for a 6 month old baby that would require hospitalization and is hereditary.

Jordyn Says:

Okay, first I have to confess that I got the answer to this question from a physician co-worker who is an encyclopedia for crazy medical conditions. If your child is that zebra in the forest, she will figure out what it is so thanks Cathy for this answer.

A perfect condition would be a Fatty Acid Oxidative Disorder. In this case, a long chain mixed fatty acid oxidase deficiency. Now, before your eyes glaze over with that– I could never write that— checked out look like I may have had in high school algebra you could simply say the child had an inherited metabolic disorder.

The child would appear to be normal and all body symptoms normally functioning until something happens to cause the child to fast such as stomach flu (gastroenteritis) that would cause the child to stop eating due to vomiting.

This definition comes from the follow link:

Definition: Fatty acid oxidation disorders are inherited conditions that affect the way a person’s body breaks down certain fats (fatty acids). A person with a fatty acid oxidation disorder cannot breakdown their stored fat for energy. Consequently, the body begins to fail once food the person has eaten runs out. In addition, fatty acids build up in the blood. In the case of fatty acid oxidation disorders, the inability to break down fats for energy and the build up of fatty acids can cause serious health problems.

In a normal, functioning body, when you no longer are taking in food, your body starts to metabolize muscle and fat for energy. This is actually the basis of some diets that cut out carbs in order to get you to burn fat. It puts your body in a state of “ketosis” which isn’t necessarily an awesome thing– but I digress.

When the body is burning muscle and fat for energy, you get a build-up of ketones in the blood. We can actually see the body is burning ketones by performing a urinalysis that shows ketones.

In this case, what would actually point the physician to think about this particular metabolic disorder is the absence of ketones in a state where the patient would normally be ketotic. For instance, the blood sugar would be dangerously low (10-20– where you could actually seize.) Normal blood sugar is 60-100. When the blood sugar is low, the body should naturally go to protein (muscle) and fat for energy because it is very self serving in wanting to stay alive. On the urinalysis, there would be absence of ketones showing the body’s inability to breakdown these tissues.

Treatment would include infusing a high sugar solution (like D10).

Top Three Pet Peeves of Pediatric ER Nurses

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?