Author Question: Unconscious Teen Struck in Head by Baseball Bat

Ari Asks:

Hello and thank you for this blog. It’s a brilliant resource and I’m grateful to have the opportunity to reach out to a professional in this setting.

I have two scenarios in a novel I’m writing that I could use your help with.

First, a teenage boy is struck in the head with a baseball bat. He is knocked unconscious and falls into a coma. When he arrives in the ER, I would like some compelling dialogue between the first responders to convey his condition, rather than just typing it out in the slug lines. What are some of the measures that nurses and/or doctors would take in responding to this injury? Also, what type of jargon or verbiage would make this scene convincing to someone in the field?

Second, is the scenario where the doctor informs the parents of the same boy about his condition. In what setting would he/she do this? Or for that matter, who would be the person to inform the parents to begin with?

Thank you for taking the time to help writers do your profession justice.

Jordyn Says:

Hi, Ari. Thanks for reaching out and all your compliments regarding the blog. I’m glad you’ve found it helpful.

Typically, when a patient arrives to the ER via EMS, they give a report on their patient when they get to the assigned room. In this case, it might be something like this:

“This is John Doe, age 17, struck in the head with a baseball bat at 1600 today. Pt with immediate LOC (loss of consciousness). Was unconscious upon our arrival. Responds only to pain. We started an IV, drew labs, and started normal saline TKO (to keep vein open). His Glasgow Coma Score is eight (this is bad). Vitals signs are as follows: Heart rate 100. BP 124/62. Respirations 16. Pulse ox 100% on 100% non-rebreather. Parents are here. No chronic illnesses. No drug allergies.” 

The ER team will place him on a monitor, assess the status of his IV, and do a thorough physical exam of the patient including an extensive neurological exam. I would follow the link above and do some reading on the Glasgow Coma Scale and how it’s scored.

A Glasgow coma score of eight or less will likely lead to the patient being intubated because there is concern that he would not be able to maintain his airway.

Taking into consideration this patient’s mechanism of injury and the fact that he is unconscious, he would receive an expedited CT scan of his brain to look for injury— likely bleeding in this case.

Past this, it would be hard for me to talk to you about all the things the medical team would say. It’s your scene. If it is a compelling scene in the novel, I’d have a medical person review it.

Keep in mind the POV character you’re writing the scene from. If it comes from a medical person’s perspective, then the use of technical terms, etc is more warranted because they should sound like they know what they’re talking about. If the scene is from a lay person’s POV— then you can write more generally about the medical things being done.

Who informs the parents about their son’s condition? These days, parents are generally not separated from their child, even in instances where the child has lost their heartbeat. The parents likely followed the ambulance and would be updated upon arrival in the patient’s room. A nurse or a doctor can update the parents and give them the medical plan of care as outlined by the physician.

Hope this helps and happy writing!

Author Question: Nurse Comforting Orphaned Child

Erynn Asks:

First Question: What’s the protocol when a child is brought in after a traumatic event (like being the sole survivor of an accident) while waiting for next of kin if they’re not local? I had originally written a scene where a nurse was comforting him, but I feel like I remember a reader telling me they wouldn’t be allowed to hug or hold a child . . . .even if they’re alone. Is this correct? Are there nurses who wouldn’t care and would do it anyway?

Second Question: Would CPS (child protective services) necessarily be involved? The child in question has an adult sibling and a will exists that will show that he should be the guardian. Would there be any hoops for him to jump through before they let him take him home?

Jordyn Says:

I’ve worked as a pediatric ER nurse at two different large pediatric medical centers and have never been admonished to not hug or hold a child if that’s what they emotionally required. I actually find that utterly shocking any hospital would tell their nurses not to do this— though obviously understand why.

A pediatric nurse will always provide age appropriate care. Infants and toddlers usually need to be held to be comforted. With a school age child or older we would go based on the child’s cues. We would probably ask, “Do you need a hug?” or “Can I sit with you?” Sometimes, open ended questions are hard for kids who are dealing with traumatic events to answer. Questions like, “What do you need right now?” probably won’t elicit much of a response so the nurse will ask very pointed questions.

Who else could assist the child? An ED tech. A volunteer. A child life specialist.

I think you’d need to place close attention to where this novel is set and the hospital would need to match your setting. Community ER’s (common in rural areas) are more comfortable dealing with the adult patient so they might approach this situation very differently and not have as many resources available.

Child Life specialists are generally not staffed 24/7 so I would keep that in mind. I also haven’t found them outside pediatric hospitals. Same with chaplains– may not be available 24/7. Depends on the type of hospital.

As a pediatric institution, we also would probably not involve Child Protective Services though probably social work consultation would be advisable in this situation. In CO— we generally reserve CPS for concerns for abuse.

If the adult sibling could prove legal guardianship in the case of the death of the parents than the child would be released into their care. Even in the case of lack of paperwork, the child would likely go to next of kin, of which it sounds like would be this sibling.

Happy writing!

PSA: Drowning Doesn’t Look Like Drowning

This is an educational post from your friendly neighborhood pediatric nurse.

During summertime, pediatric nurses are confronted with an increasing incidence of preventable injuries— the biggest one in my opinion is drowning.

It is not uncommon to get pediatric near-drowning cases in the summer. Obviously, more kids are playing in large bodies of water whether it be a shallow baby pool, regular pool, lake or ocean. Kids can drown in very shallow water. Also, just because your child has passed a few swimming lessons doesn’t mean they won’t drown. Kids in open bodies of water should be wearing life jackets.

The classic set-up is a party where there is some type of pool where all the kids are enjoying themselves. The adults are drinking and socializing and no one is watching the children play. Some adults feel that the older kids can keep an eye out for the younger ones— I cannot scream enough at the top of my lungs how patently false this is. If you have a teen who is a certified lifeguard and is tasked with watching the children in the pool I might agree. Otherwise, no.

At any party where kids are swimming, including a little tiny baby pool, there needs to be a sober adult who is watching the children AT ALL TIMES! I truly cannot express this enough. Drowning can happen in a minute or less. You cannot merely check on them every ten to fifteen minutes— that can be too late.

Also, drowning may not look like drowning and I’m including a couple of videos that highlight the point.

Enjoy the summer, but be safe! Keep an eagle eye on those kiddos enjoying the water.

Author Question: Small Town Care for Complex Medical Patient

Holly Asks:

In the very first chapter of the story I’m working on, the main character gets sent to hospital. The character in question is a sixteen-year-old female who has been missing for eleven years. She is found in the woods surrounding the town it’s set in and presents naked, severely malnourished, heavily pregnant, and with a gunshot wound to her leg. There are other superficial injuries that one might get when attempting to flee nude through dense woodland. The town and hospital are relatively small. The hospital has seventy-five doctors and forty-five nurses on staff and it’s in a fairly isolated location.

I’ve got a few questions:

1 – Would the hospital I’ve  described be able to treat a patient in this condition? What would be the basics of this treatment?

2 – Is there a procedure hospitals have in place for patients who act violent? My character hasn’t been around people for eleven years. She’s borderline feral and she attacks a doctor when she wakes up. Since she’s pregnant, I wasn’t sure if they’d be able to sedate her.

3 – Can doctors share information about patients with police officers? Since she’s a missing person and a minor, the police are going to be involved but I’m not sure how much doctors can share.

Jordyn Says:

Hi, Holly! Thanks so much for sending me your questions. These are complex ones for sure.

Question #1: Could a small town rural hospital be able to care for this patient? Maybe. One thing I want to clear up is your ratio of doctors to nurses. Usually, there are many more nurses in a given area than physicians so maybe adjust your numbers if you’re making a point about this in your novel.

When I first read your question, I thought the medical care aspects might be cared for by a rural hospital, but it was going to be a tough undertaking. This victimized teen is going to need, at a minimum, five services to be in place to stay in a rural hospital— a good general practitioner (to manage her overall care), a nutritionist (for the malnutrition), a surgeon (surgical evaluation of the gunshot wound), an OB/GYN (for the pregnancy), and a psychiatrist and/or psychologist (just because she’s been held hostage for eleven years.) Already that list is going to be tough and likely insurmountable for the area you mention.

What tilts the balance for me in saying she would have to go to a large, urban center are the psychiatric issues you mention in your second question.

Question #2: Yes, hospitals have procedures in place for violent patients, but the staff and mental health care specialists who will be required to manage her care are likely to be found at an urban center.

Violent patients are generally managed in a step-wise fashion. Can talking to them de-escalate their behavior? Is there something they’re requesting that we can give them to get them to calm down? Does she have some sort of object (like a stuffed toy) that giving her would help if it was safe for her to have?

If it’s more a fight response because of what she’s been through and she’s a danger to herself and others then she’d have to be restrained and placed under one on one observation. This type of patient can tax staffing resources which is another reason why transfer might be best.

Each drug is given a category related to its potential to harm a developing baby that is easily searchable via the internet. The categories go from Category A to Category D. Category A is deemed safest to D which has proven adverse reactions in humans. Just because a drug is listed as Category C or D doesn’t mean it might not be used. Several things would be taken into account— what we call risks versus benefits.

For instance, if she was late in her pregnancy, the doctors could risk it because the baby is fully developed. This is tough, though. Many physicians will err on the side of what’s safest for the pregnancy. However, you can’t leave a patient restrained forever and some form of psychiatric medication could be warranted here.

Question #3: Can doctors share information with police officers? Yes, they can. There is actually a special provision listed in HIPAA (the law that rules over patient privacy) that allows for this. Police officers mostly need to document what “serious bodily injury” the patient has suffered so they can determine what criminal charges to bring against a perpetrator.

The other thing to consider is the size of the local police department. Small towns may not even have their own police department but rely on the county sheriff’s office and/or state police to handle the investigation of this crime.

I actually think the best place for this teen would be the closest children’s hospital. Children’s hospitals have specialized teams in place to manage issues particularly around crimes against children. The caveat would be her pregnancy— for which she would likely deliver at an adult center.

Hope this helps and good luck with your story!

Button Batteries: Preventable Cause of Pediatric Death

There is nothing that will raise the ire of a pediatric nurse more than a preventable pediatric death. So, in an effort to educate the public, today I’m focusing on a very real danger in your home that could kill your child if ingested and that is the button battery.

battery-106353_1920Button batteries are those disc shaped, silver batteries that are found in hearing aids, watches, weight scales, and often toys. I would be surprised if you didn’t have these in your home.

Typically they are swallowed by younger children (age 1-3) who may or may not tell you what has happened. We can tell the difference between a button battery and a coin by a characteristic halo appearance of a button battery on x-ray. If you look at the underside of the battery, you’ll see this gap that will show on film.

If the battery becomes lodged in the upper esophagus, it leaks a highly caustic alkaline solution, even if the battery is spent, that begins to erode through tissue. This process happens quickly. I’ve seen these burns develop in just two hours. These burns can lead to scarring and long term complications— that can be a minor complication.

There is also a deadly complication. Even after the battery is removed, this alkaline solution can remain in place, eroding and burning away tissue. Typically, the cause of death in a button battery ingestion is hemorrhage because this solution eventually erodes through a major blood vessel. Even if the patient is in a hospital when the bleeding starts it is very difficult to repair.

For prevention:

1. Button batteries need to be treated as highly toxic objects. They should be kept out of the reach of children (even locked up) like other dangerous objects in your home.

2. Toys that have button batteries need to have screws that lock them in place. Toys should be checked frequently to be sure this compartment stays locked. Best case is not to have these types of toys in your house at all with younger kids.

3. Be aware of items in other environments that have button batteries. Button batteries are used in hearing aids. So be careful at grandma and grandpa’s house and have a discussion with any caregiver about the dangers of having these unsecured.

4. Give age appropriate education to other children in the home about how dangerous button batteries are. Tell older children to tell you immediately if they see a younger sibling with anything in their mouth that they’re not supposed to have. Have them show you toys when they break to see if the battery has become loose. If it’s not there— find it.

5. If swallowed, proceed immediately to the closest emergency department. I mean, really drive there now. You don’t need to call 911 but you do need to go. Do not delay being seen. Button battery ingestions are a true emergency. Your child should immediately receive and x-ray to determine the location of the battery. Treatment depends on its location.

6. If discharged home after a button battery ingestion, any bleeding needs to be treated as an emergency as well. If bleeding is significant then you should call 911 and be transported. Even minor (or spot) bleeding from the mouth needs to be evaluated emergently.

For additional cases and information you can read here and here.

As one of my physician co-workers said, “Respect the button battery.”

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