Trauma

The Use of Hypothermia Post Cardiac Arrest

/ Jordyn Redwood / Leave a comment

Emily Asks:

I am playing around with one of my character’s being shot life threateningly, but of course it’s gotta be something he recovers from with time.

This character is in his late 20s and in good health before the incident takes place.

At first, I was toying around with the idea of making the gunshot wound similar to what Kate Beckett had in the show Castle at the end of season three. The trouble is, I do not know how medically realistic her wound was, as you have pointed out Castle’s medical inaccuracies before. If you have possibly seen the episodes in question, could you give me some feedback on the medical aspects of Beckett’s shooting?

In relation to this, her heart supposedly stopped twice during the whole ordeal. I have been researching induced comas, and while they seem to be used for patients having more of a direct injury to the head, in the case when a victim’s heart stopped twice and is resuscitated both times, would there be any reason to keep them in an induced coma for a time due to lack of oxygen to the brain?

Then, after researching, I am playing around with giving this guy a collapsed lung from the bullet, which is small caliber.

1. In what hypothetical cases would this kind of injury require immediate surgery?

2. Are there any complications that could be serious enough for the said character to have to go back into surgery at a later time?

3. My character happens to be a bass singer for an acapella band. Would a collapsed lung affect his career at all even after he made a full recovery?

Thank you for taking the time to read and respond to my questions!

Jordyn Says:

Beckett’s Gunshot Wound:

I had to go back and find some videos that were related to this. Shockingly, I found this scene pretty medically accurate. I found one that showed her coding one time. Though I definitely could have missed some. The determination to put someone in therapeutic hypothermia or targeted temperature management (as now termed) related to their heart stopping is dependent on whether or not they wake up immediately after their code.

A patient that wakes up spontaneously and quickly after a pulse is restored has intact neurological function. Those that remain comatose have a concern for neurological injury related to oxygen loss to the brain during the resuscitation and therefore the medical team could choose to put the pt in a “hypothermic” state to try and prevent this neurological injury.

This is slightly different from a medically induced coma that patients with traumatic brain injury might be placed in to prevent brain swelling. The difference is actively cooling the patient. I have not seen the use of hypothermia in the traumatically brain injured population (though this does appear to be an area of study), but use of medically induced comas, yes.

There are definite guidelines that the American Heart Association has put out that outline this course of treatment. You can find one such article here.

If your character codes and doesn’t wake up– then this would be a reasonable course of action medically, but written under the guidelines in the article.

In regards to your specific questions.

1. It’s more likely than not that a gunshot wound to the chest would go to surgery, particularly if the patient presents with any abnormal vital signs especially low blood pressure. There’s just so much there that could be damaged. The heart. The lungs. The blood vessels.

2. Yes, there could be a number of scenarios where the character could require more surgery such as a blood vessel that’s leaking that’s not found the first time during surgery and continues to bleed. Infection– specifically some sort of abscess formation could be another reason, but that would take some time to develop.

3. I don’t personally foresee a problem with his acapella career after his lung is healed. It would take time to get to the point where he was. If you wanted to affect his career, a patient who is intubated (placed on a breathing machine) can develop vocal cord damage as a rare complication.

Best of luck with your story!

Treatment of Car Accident Victim with a Brain Injury

/ Jordyn Redwood / Leave a comment

Leslie Asks:

My character has been in a car accident and sustained head damage (swelling to the brain)— is there a medical term for that? Also, the swelling becomes so bad the doctors have to remove part of her skull— is there a name for that? How long does that swelling usually take before it goes down so they can replace the skull? Does the character regain consciousness? I have her in an induced coma which I want her in for a while.

Jordyn Says:

Upon further clarification of this question from the author, she says there is not a significant description of the motor vehicle collision in the manuscript and the scene is being told from the POV of a nurse.

The brain swelling is called cerebral edema. Usually, if it’s a significant car accident then there is usually bleeding as well. This is why I ask about the car accident. It should be pretty serious.

A nurse will use language that a family can understand. So, I might actually avoid a lot of medical terminology when speaking to the family unless I also clarify what the words mean.

I might say something like, “Your mother (or whatever relation) has a lot of swelling in her brain as a result of the car accident. We call this cerebral edema.”

A craniectomy is where they remove a portion of the skull.

Peak brain swelling is generally 48-72 from the time of injury and diminishes from there. Induced coma is a reasonable medical scenario here.

Whether or not this patient regains consciousness is up to you as the writer. Statically, the odds are pretty low for her to be the same person she was before. If she does wake up, she’ll have extensive rehab needs for sure– but you could write it either way.

Best of luck with your story!

Author Question: Motorcycle Injuries

/ Jordyn Redwood / Leave a comment

Tory Asks:

I’m currently writing a fan fiction and the two main characters get in a motorcycle crash. The female just found out she was pregnant. I have three (very unrelated) questions. Could the crash send her into cardiac arrest? Would the male (who was driving) be able to survive with just a broken arm and a sprained ankle? And would the baby survive?

Jordyn Says:

Hi, Tory. Thanks for sending me your questions.

1. Yes, a motorcycle crash could send someone into cardiac arrest.

2. Could the male survive with just a broken arm and a sprained ankle? Sure, this is possible, but I don’t know if it’s probable. When looking at accidents, medical people always look at the injuries of the other people involved to determine how serious everyone’s injuries might be.

If the female in the accident suffers a cardiac arrest, it would be surprising that the male walks away with just, essentially, a broken arm. You could make it more believable in the description of how the accident happens. For instance, the female is thrown from the bike, but the male is trapped underneath it. You could also have them differ in the type of protective equipment they’re wearing (helmet, jackets, etc.)

3. Would the baby survive? Again, it depends on a lot of factors. How far along is she in the pregnancy? Cardiac arrest— how long is she pulseless? What other injuries does she get in the accident? The sicker she is from her injuries, the more likely she will miscarry the pregnancy. The body will defer energy and resources to the mother over the pregnancy. Then again, some women have maintained a pregnancy through terrible injuries so you would have some leeway as an author here.

If the mother is far along in the pregnancy (at least 22-24 weeks along) and in cardiac arrest the providers might consider C-section to save the infant. So, without more details as to the nature of the accident, her injures and the state of her pregnancy, it would be hard to say if the baby would likely live or die.

Good luck with your story!

PSA: Drowning Doesn’t Look Like Drowning

/ Jordyn Redwood / Leave a comment

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: Gunshot Wound to the Torso

/ Jordyn Redwood / 2 Comments

Heather Asks:

If my hero gets shot in the torso, is there somewhere it can hit that won’t be fatal? It can be a “miraculous” miss, that kind of thing. He can be weakened and bleeding, but I just need him to stay conscious for maybe five to ten minutes after? Any ideas?

Jordyn Says:

Sure, there are always miracles.

In medicine we view the torso as including the chest and abdomen. Generally the diaphragm is the dividing line between the two. So the chest is everything above the diaphragm and the abdomen is everything below it.

Gunshot wounds to the chest not hitting anything is tough. Think about everything that’s there. The heart, lungs, major vessels and arteries. Can a bullet pass through and miss everything— or hit something less minor and just cause bleeding? Sure. Anything is possible. I would recommend staying away from the left side of the chest for the wound— just so much there. The right chest and lower might be more believable because it’s just the lung sitting there. There are major blood vessels that underline each rib so nicking one of those could cause the bleeding you want. Hit outside or inside enough and you could miss the lung.

Abdominal wounds could go either way. A lot to hit in the belly as well, but also good odds for missing. If he’s wearing a bullet proof vest, you could have the bullet enter through his side and low– just under the lung and diaphragm. Problem is you have highly vascular organs on either side– the liver on the right and the spleen on the left. So, I’d aim below that as well or merely have them be grazing wounds to these organs. This could also cause significant, but survivable bleeding.

Hope this helps and happy writing!

Author Question: Flesh Wound to the Stomach

/ Jordyn Redwood / Leave a comment

Heather Asks:

If someone got sliced by a knife (lightly— not deep) in the stomach, I know they’d get stitches, but would they be able to move around the next day or would it take a couple of days or more? If so, I’d better move that slicing injury. The slice did not go through the muscle.

Jordyn Says:

If the cut doesn’t go into the muscle, the character should be fine getting stitches and then being able to move. It might be mildly sore, but not crippling by any means.

Keep in mind, depending on the size of the wound, a lot of movement can pop stitches. If he’s doing a lot of strenuous activity, and the wound is large, even if it doesn’t go through the muscle, the movement could pop the stitches and open the wound.

Also, any wound, even stitched close, is at risk for infection. Could be another complicating factor for your character.

Happy writing!

Author Question: What Happens to the Child of an ER Patient?

/ Jordyn Redwood / Leave a comment

Susan Asks:

I am wondering what happens when a mother is injured and her seven-year-old child is with her. The unconscious woman is discovered by a passer by who calls 911. She wakes up, an ambulance arrives and she is taken to the ER.

I assume the child who is fine would go with them if the police haven’t been called. The woman is from out of town and knows no one in the city so the child can’t be picked up by anyone. The mother has a concussion and is kept overnight for observation. I am most interested in learning what would happen with the child at the point that they arrive at the ER while the mother is being examined.

Jordyn Says:

From the EMS standpoint— yes, they would bring the child with the parent.  As far as in the ER, if the mother is awake, the child would be in the room with her. The ED staff can assist with care of the child until the mother is feeling like she can manage. A child this age could be given activities to keep them entertained (coloring, snacks, a movie, etc).

If the child needs more than that then a member of the staff (like an ED tech or volunteer) could provide some assistance until the mother is feeling better and able to care for the child on her own.

Also, a concussion is not a reason for admission to the hospital. Not even overnight observation. Concussion patients are generally not admitted— even with a loss of consciousness at the scene. Even a minor car accident with loss of consciousness does not require admission if everything else is okay.

You don’t specify her mechanism of injury in your question. For concussion we want to see them alert and oriented and that their concussion symptoms (headache, dizziness, nausea) improve or resolve. CT scanning is more common in the adult population for head injury so if that shows no bleeding then there’s really no reason for her to stay in the hospital. If you need her admitted, I can help you have the character meet admission criteria.

Hope this helps and happy writing!

Author Question: Pediatric Fall From Skateboard

/ Jordyn Redwood / Leave a comment

Carol Asks:

A four-year-old falls off a moving skateboard onto a driveway (no helmet, or pads.) Someone was doing something he wasn’t supposed to do.

This is what I’m proposing happens to this child.

Result: Greenstick fracture in one of the bones of the forearm and possible concussion?

Treatment: Cast in ER and keep overnight for observation? Possible sedatives or stronger meds (like codeine) for pain that may make her sleepy?

Follow: Specialist?

Jordyn Says:

Thanks, Carol, for sending me your question.

I’ll answer in the same way you sent your scenario to me with my opinion.

Result: Yes, greenstick fracture is good. You can hit the link for further information. However, we don’t use this term (as least not in Colorado.) We say “buckle fracture” as in the bone buckles or squishes a little. Bones in this age group are very pliable. This is a very common fracture in kids. The fracture is not a line crack through the bone. Concussion, yes. And you’re right– this kid needs a helmet on!

Treatment:

Splint in the ER. Casting is rare in the emergency department. The difference between the two is a splint only has hardening material on one side and is secured in place by an ace wrap. This leaves space for the injury to swell and can limit the potential for developing compartment syndrome— though that would be rare for this type of fracture. Casting has circumferential hardening material— usually something like fiberglass sheeting that hardens. Also, some providers are just placing a removable type wrist splint on these fractures since they are very stable and the child will usually self limit activities until the pain goes away.

I’m going to assume your child/character has a mild concussion. No loss of consciousness. No amnesia. Maybe a headache, nausea, dizziness, etc. We would not give any sedative or narcotics to this patient— for the concussion nor for the fracture.

Ibuprofen is the preferred drug of choice for the fracture and even for the headache that might be associated with the concussion. Some providers are against ibuprofen in concussion because of a concern for increased bleeding (ibuprofen makes platelets less sticky), but that’s with multiple dosing. We give Ibuprofen often to kids with head injuries and they do fine. Acetaminophen can be given for headache and it will help with pain from the fracture, but it will do little to help the swelling of the fracture. This is why ibuprofen is preferred for broken bones because it helps with both pain and swelling.

Assuming this child has a normal neuro exam and is at their normal neurological baseline (meaning, they are acting as they normally do at home)— then they would be sent home. There is no reason to obs this kid overnight.

Follow up: With orthopedics in 7-10 days for reevaluation of the fracture with cast placement. Cast would be on for 4-6 weeks.

Hope this help and good luck with this story.

Author Question: Small Town Care for Complex Medical Patient

/ Jordyn Redwood / 2 Comments

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!

Author Beware: Taking out Perfectly Good IVs

/ Jordyn Redwood / Leave a comment

If you’re a frequent reader of this blog then you know I have kind of a love/hate relationship with James Patterson. Love his books (most of them), but I frequently take him to task for medial inaccuracies. I rarely call out an author in person or name their book because I like to mostly teach on medical topics, but I think James could use a medical consultant and I also think he has enough money to afford one– though I think these posts are not increasing my chances of working for him.

Anyway . . .

In one of his recent titles, Woman of God, the first part of the book highlights the main character serving as a physician in a war torn region.

Early in the novel, a young boy comes to their primitive hospital suffering from a bullet wound to the chest. During the surgery, which involved opening up the side of his chest, it is noted that the patient stops breathing and so the surgeon, a mentor of the main character, just gives up.

First of all, a patient receiving major surgery like this should be intubated and anesthetized. They do offer surgery, so must provide this to most of their patients. Earlier in the chapter, it is noted that the patient is being bagged and anesthetized patients can’t breathe on their own anyway— so why is a decision made to let him die when he stops breathing when, if properly cared for, he shouldn’t be breathing anyway?

However, this situation does not deter the main character and she continues his operation.

“The heart wasn’t beating, but I wasn’t letting that stop me. I sutured the tear in the lung, opened the pericardium, and began direct cardiac massage. And then, I felt it— the flutter of Nuru’s heart as it started to catch. Oh, God, thank you.

But what can a pump do when there’s no fuel in the tank? 

I had an idea, a desperate one. 

The IV drip was still in Nuru’s arm. I took the needle and inserted it directly into his ventricle. Blood was now filling his empty heart, priming the pump.”

Where to start, where to start.

First, it’s never noted that this patient is receiving blood. I think this is an add on by the author for effect. Secondly, remember IVs are not needles, but very small plastic catheters, that would not be able to puncture through the tough muscle of the heart.

Thirdly, and by far the most egregious, the physician takes out a perfectly good IV for a nonsensical reason! It is hard, really hard, to get IVs into sick kids— particularly those suffering from hemorrhagic shock like this boy is from a gunshot wound to the chest. That one, lonely IV you took out to puncture his heart (not a good idea either), you’re going to need back because this kid will still be sick. You’ll close his chest and then have to find more IV access. Giving fluids via a vein can rapidly fill the heart and it is insanity to take out a good IV to do what the text suggests.

Call me, James. Really. I’m not as expensive as you might think.