This Is US: Jack’s Needless Death

This television episode caused more people to reach out to me over any other. This Is Us has been building up to Jack’s death for eighteen months. It needed to be big. It needed to be dramatic. Can you tell I’ve been watching the show? It was really none of those and medically— well, just weird to be honest.

If you haven’t watched the episode then don’t read this post because it will reveal his cause of death . . . like right now.

Jack’s ultimate demise? A heart attack called the widow maker caused by the stress of the fire.

Jack is in intense smoke and heat for several minutes. He emerges and is first checked by EMS. He is being given oxygen and a dressing to his arm for “2nd degree burns”. The EMS person says she can’t treat the burn and he is seemingly refusing transport, but she does encourage him to be seen. Also, giving oxygen is correct, but it is not the right type of mask. A note on burns. Burns will evolve over the next several days so you don’t really know how severe a burn will be for a while.

Jack does eventually go to the hospital to get his burns checked. The doctor is initially giving him instructions on burn care.  The doctor says, “I’d like your heart rate to come down.” and glances at the monitor— which doesn’t have any readings on it. No waveforms. No numbers. He then says, “There’s soot in your airway so we’ll have to run some tests. The swelling is minor.”

That’s about it. The doctor tells Jack he basically dodged a bullet and seems none too concerned about his potential airway damage.

Just as I mentioned above, airway burns from smoke inhalation are similar to skin burns in that they evolve over time. Smoke inhalation and the potential for upper airway swelling is taken very seriously. There is a nice overview here. At the very least, there should be discussion of admitting Jack to the hospital. As quoted from the article, “Studies have shown that initial evaluation is not a good predictor of the airway obstruction that may ensue later secondary to rapidly progressing edema.” If there is concern about significant injury to the airway then the patient is electively intubated until the airway injury heals. It’s VERY difficult to intubate someone with a lot of airway swelling.

Shortly after this consultation, Rebecca decides to make a phone call and get a candy bar from the vending machine. In that, perhaps under two-three minutes passage of time, Jack codes and dies. Even though she is just outside the ER nurses station, she never hears a code being called. Doesn’t see the commotion.

The doctor approaches her and says, “One of complications of smoke inhalation is that it puts a terrible stress on the lungs and therefore the heart. Your husband went into cardiac arrest. It was catastrophic and I’m afraid we lost him . . . Mrs. Pearson, your husband has died.”

After a few exchanges she goes to Jack’s room where there is a spotlight shining on his chest with a cursory ambu bag at the head of his bead . . . but no other equipment. I’m telling you in two minutes, a code has barely just begun and is never called so hastily . . . like ever. Later, explaining the event to Miguel, Rebecca says he had a widow maker’s heart attack.

The widow maker is a real term for a heart attack. It generally refers to occlusion of the left main coronary artery that feeds the left side of the heart. It is the same heart attack celebrity trainer Bob Harper had and survived. The reason the widow maker can be so devastating is that the left ventricle is the largest, strongest pumping chamber. If it dies . . . well, you’re hosed.

There would be no realistic way the doctors would know it was specifically this kind of heart attack as shown in the episode without an autopsy. Presumably, Jack went into one of the lethal heart rhythms, v-tach or v-fib, at the time of his code. In the time frame given on the show, the medical team would have barely started CPR and given the first line treatment which is electricity. A 12-lead ECG can be a strong diagnostic tool for this type of heart attack, but they never did one. Had they done that early on, they probably would have seen the changes.

Also, he would likely have some signs and symptoms. Chest pain. Nausea. Left arm pain. Sweating. Demonstrating these might make the scenario seem more believable. Having Rebecca witness the code would have been more dramatic.

Also, it would make more sense that he would suffer this cardiac event while he is actually under duress— such as during the rescue of the children and the dog.

The only way to truly know that this is the type of heart attack Jack suffered as presented in the show would be to conduct an autopsy.

This Is Us— thanks for killing off a beloved character in a totally lame way— at least from a medical standpoint.

Pediatric CPR: When to Stop?

Nothing probably tugs at the heartstrings more than thinking about a child dying. It’s not the way things are supposed to happen. We expect life to follow the natural order of things— the old die first. Parents should never bury their children.

Sadly, we know this reality is not true. The pediatric nurse understands and confronts this reality more often than most. Particularly nurses who work critical care, ER, oncology, and hospice.

A reader of this blog posed this question to me: How long will a nurse or doctor perform chest compressions on a pediatric patient? Is forty-five minutes too long or would they try longer?

This is a tough question and not so easily answered. There are really no hard and fast rules as to when CPR should be stopped and it depends a lot on the reason for the code (if known) and what types of signs the patient is giving us. For instance, just because a patient doesn’t have a pulse, doesn’t mean they don’t have electrical activity in the heart muscle. Some causes of a code are reversible, but it takes time to do so. Hypothermia might be a good example of this.

I’ve worked in both adult and pediatric critical care. What I’ve found generally is providers will run pediatric codes longer than adult codes even when chances are small to get a pulse back. No one wants to see a kid die— health care providers are no different. Plus, culturally, we resist death at every turn even though it is the course each of us will journey to.

However, I did come across this article that begins to address this concern. If we can teach how to resuscitate patients— should we also not teach providers when it is reasonable and ethical to stop such efforts?

1. Are there clinical features present prior to the code that are predictive of poor survival? For instance, in the adult patient some of these from the article included pneumonia, metastatic cancer, and low blood pressure. For pediatric patients, kidney failure and use of a continuous infusion of epinephrine are mentioned.

In the emergency department setting, we want to know what the patient’s initial heart rhythm was. If there was no electrical activity in the heart (terms such as asystole, flat-line, ventricular standstill) then chances of getting back organized electrical activity AND contraction of the heart muscle are low.

2. Is the patient receiving high quality CPR? This might seem like a no brainer. Of course, if the patient codes in the hospital, they must be receiving excellent CPR. What research shows is that this is not true and it is a big drive of many institutions to simply improve the quality of CPR. If I can ease your mind, many hospitals are improving CPR basics through high fidelity code labs, more frequent CPR check-offs, mock codes, and computer based CPR training that measures effectiveness of CPR and coaches the participant on how to improve .

What are some CPR pitfalls? Initiating CPR in a timely manner. Compressing deep enough and at the right rate. Not over or under ventilating the patient (both can actually cause problems). CPR is what we call a high risk, low yield procedure— meaning we don’t do it very often, but when we do we have to do it right. What you don’t practice frequently you don’t become adept at. CPR is no different.

Considering this, we look at how long the patient’s down time was. This refers to the time when the patient’s heart stopped beating to the time they got CPR. Trouble is, this might be relatively hard to determine. When was the patient last seen? Is the patient cold to the touch? Are their pupils fixed and dilated?

The good news for the writer is there is a lot of leeway in this area as far as how long a medical team might “work” on a patient. Factors can be given for both short and long resuscitation times.

The most important part is getting those factors medically correct.

What about you? Have you written a resuscitation scene into a work of fiction?

 

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.

New Medical Device: Zoll R Series Defribillator

It’s difficult for new medical devices to impress me. This one did.

One of the challenges in medicine is doing effective CPR. Research studies have consistently shown that what generally saves a patient’s life is early and effective CPR. That’s when all the other bells and whistles that we have in our medical stockpile will work.

However, you might be surprised at how ineffectively we do CPR. For one thing, it’s physically hard to compress the chest enough to generate a pulse. Second, it’s tough to measure the effectiveness of compressions. The way this is traditionally accomplished now is through palpating a pulse during CPR (which is difficult to do accurately) or to measure what’s called end tidal CO2 which is best accomplished when a patient has a breathing tube down their trachea.

Another difficulty in doing CPR is the amount of artifact it creates. Artifact is something you see on the monitor that isn’t a true representation of the patient’s condition. For instance, if a patient is connected to a monitor and you pick up their ECG leads and shake them– you can make it look like they’re in a lethal cardiac rhythm.

If you’re doing effective compressions, you can’t see the patients underlying rhythm but stopping CPR to check a patient’s rhythm takes away from its effectiveness as well. It takes a while to establish pulsatile flow with CPR so every time you stop, the patient can suffer.

The Zoll R Series Defibrillator attempts to change some of these issues and if it is able to do what it says– it could mean a big improvement for patient care.

It has a pad that is placed at the center of the patient’s chest. This measures the effectiveness of compressions and makes sure they are at the right rate and depth. It also allows you to see the patients underlying rhythm while compressions are ongoing which can lead to better treatment at the bedside when a rhythm changes.

It will be interesting to see if a device like this will decrease the morbidity and mortality around code events.

I was not paid by the company to review this product.