Five Things This Is Us Got Right About Medical Care

Usually, when I write these blog post, it’s a scathing review of something a television show or movie got wrong. However, in a recent episode of This Is Us entitled The Waiting Room, there were several things that the show got startlingly right for a change. Chrissy Metz’s character, Kate, was in preterm labor leaving the family to dwell in the waiting room. Here’s what the episode got right.

1.  People use Google all the time to question medical professionals. In the episode, one of the family members pulls up the drug Kate is on to quell her contractions and begins to question its side effects. Listen, I’m all for informed family members, but as many medical professionals know, the information on Google can be less than accurate.

It does become frustrating as a medical person to take Google’s word for a medical treatment over a trained medical professional. I’m also all for questioning a provider in a respectful way. A better way to approach this question with your provider is to ask, “What side effects are common with this medication?” and “Do you feel like those side effects are worth the benefits of the treatment?” Any provider worth their salt should easily be able to answer these questions. If not, then you may have a problem on your hands. This will tell you more than Google will be able to tell you.

2. Often times, people think that waiting equates to poor medical care. In one part of the episode, Kevin begins to question the delay in hearing any news, and openly questions if his sister should be moved to another facility, insinuating that she’s not getting proper care. The truth is, few things are fast in medicine. I think the culture and patient expectations haven’t benefited from these one hour television shows.

Nowadays, everyone wants to be seen within an hour and discharged home shortly after. In reality, especially in units where you don’t have an appointment, triage happens all the time based on how life threatening a patient’s condition is. Also, sometimes patients need to be watched for lengthy periods to see if their condition will resolve to a point where they could go home, or see if they’re appropriate for admission. If needing to be admitted, where to? Does that unit have capacity and staff to take care of the patient? Just because you’re waiting doesn’t mean anything necessarily bad is going on or that your loved one is getting bad medical care. A lot is probably happening behind the scenes that you’re not aware of.

3. Threats to staff happen a lot more than you might think. Maybe a better term for this would be microaggressions. Threatening to leave. Threatening to transfer. Threatening to call the patient care representative to file a complaint. Threatening to sue.  Using profanity directed at the medical staff and not just expressing frustration at the situation. Unfortunately, medical professionals hear variations of these every day and often without merit. They are designed, generally, to force medical care to happen more quickly. Using threats or aggression to speed up medical care is not necessarily wise for a variety of reasons. The largest reason is that stressed out healthcare workers tend to make more mistakes— the one thing you don’t want to have happen.

4. Waiting rooms are pressure cookers. It’s not unusual for arguments and fights to happen in waiting rooms. The waiting room becomes a voluntary prison and all people can do is watch the clock ticking. The more time that goes by— the more frustration builds. We are all more likely to take out frustration on our loved ones most— probably after the staff. That frustration will bleed over into other people and families.

5. Healthcare workers respond to kind and courteous over anger a lot better. In the episode, Kevin and Randall both approach the nurses’ station asking for information. Randall does it with more kindness and respect and gets more of what he’s asking. We are normal humans and it’s true what they say about honey.

This Is Us used truth and reality to make a very effective episode. Well done.

Author Question: Polar Bear versus Shoulder

Laurie Asks:

I’m a debut Christian romantic suspense author and I wondered if you could help me with a medical question.

My hero is mauled by a polar bear. He’s suffered a dislocated right shoulder, tearing of the ligaments, rotator cuff, and whatever tendons are in the shoulder and across his scapula. He’s got bite punctures on his upper arm, his right ear was bitten and repaired via plastic surgery. He’s got a scalp laceration with twenty-eight staples to reattach it.

My hero is an RCMP cop and he needs to get back to work.

Can you tell me what he’d have done surgically to repair the rotator cuff and ligaments? How long would he realistically be off work and need physical therapy?

Jordyn Says:

I reached out to Tim Bernacki, an awesome physical therapist, who rehabbed by own shoulder after I dislocated it. If you live near Castle Rock, Colorado check out clinic called Front Range Therapies. I highly recommend him.

Tim Says:

A massive rotator cuff tear (RTC) along with ligament tears and dislocation would lead to quite a surgery. One of a kind. The massive tears I’ve seen used multiple anchors (versus one or two for the “common” repairs).

Some of the massive tears also used either synthetic or pig skin patches because of the tear size. The ligaments would also need to be repaired with more anchors. This person would be in a sling with an abduction pillow at the side for probably eight to ten weeks (versus six weeks for the smaller tears).

Therapy could start earlier than when the sling comes off but would entail only passive range of motion (provided by the therapist). The tricky thing here is that if one portion of the RTC is torn, the protocol would incorporate stretching of that repair last in the sequence of stretches. Likewise, strengthening would incorporate moving in that one direction later than others.

With this person, all directions of movement would need to be respected. This person will need a truly great therapist, or I would expect them to get about eighty percent of their range/use/strength in the end. If all goes well, I would anticipate full range around four months post-op.

Strengthening would begin around three to four months post-op and could go on for at least three to four months itself. For full duty police work, minimum time from date of surgery to return to work I’d guess is eight months, but more likely around ten months. Most police officers return to working on restricted/light duty (if the injury was work related). Light duty is typically communications and/or desk work, working cold cases, helping with investigations, but not leaving the station.

Author Question: Rehabilitation after Gunshot Wound Injuries

Sean Asks:

Hi Jordyn!

Looking for a little bit of help with some 9mm gunshot wounds. I was going for non-lethal aside from possible bleeding out and injuries that would have long recovery time.

I have a character get shot at point blank range in the lower right abdomen from the front. Then in the right shoulder/clavicle, also from the front, about five to ten feet away, breaking the clavicle. Finally, in the left calf from behind from ten to fifteen feet away, breaking the tibia which is made worse when the shooter grinds his foot into it.

I’m guessing the shoulder/clavicle and calf/tibia would require a sling or cast and a serious amount of PT. The abdomen wound I’m guessing would require some reconstructive surgery depending on if and how much the bullet bounced around?
I figured it would take her almost a year to walk without assistance from those.  Am I close in that assessment? Thanks in advance for ANY help!
_______________________________________________________________________________________________

Jordyn Says:

 

Since this is largely a rehab question I reached out to Tim Bernacki, a great physical therapist, who I highly recommend from personal experience. If you live near Castle Rock, CO look up his clinic, Front Range Therapies.

Tim Says:

Generally, time frame of healing is 6-8 weeks for most things, especially soft tissue. All these injuries would require surgery. The clavicle fracture would require an open reduction/internal fixation (ORIF)—this means that there is an incision made and hardware placed to stabilize the fracture.

I wouldn’t know what is done if the clavicle is “shattered” and is in a multitude of pieces. The wound would have to be a glancing hit that results in a fracture. Anything more severe in the area could result in ruptured arteries, as well, and the person cannot die from this wound.

The tibia fracture also would require an ORIF—either plate, screws, or rod with locking screws. The difficult thing in all this would be that due to the leg recovery, the person will be using an assistive device, but probably cannot use crutches due to the clavicle pain. Perhaps a walker could be used. Depends on how conditioned the person is, how young, etc . . .

The leg injury would require limited weight bearing for 6 weeks I would guess. If all heals as expected according to x-rays, then they would transition into weight bearing as tolerated (WBAT). Probably would have a limp for several weeks after that. Likely wouldn’t run until four months following surgery if all goes well. The clavicle would probably have a sling for maybe 2-4 weeks (if no repairs to muscle or rotator cuff were done). After that, overhead reach would be most affected and for several months.

As for the abdominal injury, other than not bearing down with pressure for a short time, I wouldn’t think there are other issues to consider.

I’ve seen some gunshot wounds (GSW) where the bullet enters, hits a long bone, changes course and travels along the bone. This assumes the round is a practice round (full metal jacket) and not a hollow point. Hollow point bullets or defensive rounds open up when they hit something, resulting in a much-enlarged object/wound. I’ve seen rounds left in place because taking them out was unnecessary and I’ve seen rounds removed because of the location. Sometimes there are exit wounds and sometimes there aren’t depending on what stops the round. Sounds like there wouldn’t be an exit wound with the clavicle and leg but could be with the abdominal (perhaps in the low back).

Hope this helps and good luck with your story!

Author Beware: Good Example of BAD CPR

Sometimes, blog posts are very easy to write. I was tagged on this CPR video by a respiratory therapist friend of mine. It comes from a FB page called Enfermagen. Since I don’t speak the language, I’m not sure if they’re using this as a good or bad example of giving a patient CPR, but I’m here to confirm this is bad CPR and here’s why.

1. The patient has purposeful movement. As you can see, several times in the video the patient reaches up and attempts to move the mask from his face. Any time a patient crosses their midline, it’s purposeful movement. It definitely appears that he is sick, but he has enough of a perfusing blood pressure (and therefore pulse) for his brain to be getting blood flow in order to make these movements. Therefore, he does not need CPR.

2. The compression rate should be 30 compressions to 2 breaths. The compression depth is two inches. When the patient does not have a breathing tube in his throat (called intubation), the compressor should pause in order for the person to be able to deliver breaths. This compressor doesn’t really pause in order for the rescue breaths to be delivered. Luckily, for this gentleman, his compressor gives relatively shallow compressions and not the two inches they should be.

3. No one checks a pulse. What might help these rescuers is that when the patient starts moving, is to check his pulse. This might confirm for them that he has one and they can stop compressions.

4. Patients should not need to be restrained for CPR. CPR is for unconscious patients without a pulse. If you’re retraining the patient, they likely don’t need CPR.

I’m not sure the medical nature of this gentleman’s illness. Clearly, it looks like he does need some sort of medical assistance. It’s just not CPR.

Can you see anything else wrong with the way this team is delivering CPR?

Author Question: The Perfect Skull Fracture

Ethan Asks:

I’m looking for the Goldilocks of skull fractures. My main character is a college age male that got into a fight. I’ve tried doing my own research but I’m second-guessing myself on which part of the skull to hit. I’m looking for a crack (not a shatter), minimal blood loss, he stays conscious for ten minutes or so, and a hospital stay of about five to seven days. I’m guessing there’s no way to avoid a concussion, as long as there’s no permanent brain damage I can work with it. Is such a skull fracture possible? If so, where on the skull?

Jordyn Says:

Yes, there is such a skull fracture that I think would fit your scenario perfectly.

In a small amount of cases, patients who receive an injury to the side of their head causing a fracture of the temporal bone can tear their middle meningeal artery causing an epidural bleed.

An epidural bleed/hematoma is considered a neurological emergency. Most of these patients will require surgery to save their lives. With epidural hematomas, the patient can have an initial loss of consciousness followed by a distinctive lucid period, and then worsening neurological status after that.

This article gives a nice overview of the condition and treatment for epidural hematomas. Also, this is a good article as well.

Hope this helps and best of luck with your story!

All the HIPAA Posts in One Place

This post will simply be a reference tool for authors. Since I have so many posts about HIPAA, the patient privacy act, I decided to put links all in one place for your convenience. This would be a great link to bookmark.

General Information Regarding HIPAA:

HIPAA Part One
HIPAA Part Two
HIPAA Part Three

Specific HIPAA Topics:

Law Enforcement and HIPAA
Disclosing Protected Health Information Under HIPAA
Disasters and HIPAA
HIPAA and Identity Thefts
Author Beware: Proof’s Problem with HIPAA
Modern Family: Disclosing Pregnancy Results
Author Beware: HIPAA— It’s no April Fools

Remember, in a novel it’s perfectly okay for a character to violate HIPAA. In fact, in might be preferred to increase the drama/conflict in your story. Just remember, they need to face consequences for their actions, or it should be made clear that other characters are aware that the action did violate this law. This ensures the reader knows that you’ve done your research.

Author Beware: HIPAA– It’s No April Fools

Image by Gerd Altmann from Pixabay

One of the biggest errors authors make in regards to writing about something medical is that their character violates HIPAA. HIPAA is a law that outlines a patient’s rights regarding their protected health information (PHI). I’ve blogged extensively on this topic and you can find these posts by following these links:

Author Beware: The Law: HIPAA  Part 1/3
Author Beware: The Law: HIPAA Part 2/3
Author Beware: The Law: HIPAA Part 3/3

HIPAA and Law Enforcement
Author Beware: Proof’s Problem with HIPAA
Disasters and HIPAA
Modern Family: S10/E7 Disclosing Pregnancy Results

The simplest way to explain a HIPAA violation is that someone accesses a patient’s information when they are not directly caring for that patient and/or discloses protected health information about a patient publicly.

Two recent stories have highlighted each of these scenarios.

The first involves actor Jussie Smollett and several dozens of hospital employees accused of viewing his medical information at Northwestern Memorial Hospital in Chicago, Illinois. They were all fired, reportedly some didn’t even open the chart, but just “scrolled by” it. The point is, with today’s technology and electronic medical records, it is very easy to determine who has accessed someone’s health information. It’s basically tracked electronically. Unless you are directly involved in caring for a patient, it is illegal for you to look at their information. I can’t even access my own children’s medical charts at the hospital where I work unless I go through the proper channels, which is signing a release for them through medical records.

The second, and perhaps more frightening case, is of the nurse who disclosed a toddler was positive for measles in the pediatric ICU where she worked and then posted about it to an anti-vaxxer group she belonged to on social media.

She didn’t give the patient’s name, sex, or exact age so she should be okay, right? Many times, people think this is a way to get around HIPAA and sometimes they can be right— it depends on the volume of such a diagnosis. For instance, if my ER sees 5,000 patients a day (which is insane– I don’t know any ER that can even possibly do this) and I say we saw a patient with a rash (and that’s it) then that doesn’t necessarily signify the one I might be talking about because there were probably dozens of patients seen with a rash that day with that volume of patients. However, I will also say this could still be considered a HIPAA violation, but let me further illustrate my point.

The more unique and rare a medical diagnosis is, the more easily it would be to identify a patient even without disclosing name, sex, or age and that is this nurse’s first problem. There was probably only one patient in the PICU that had a medical diagnosis of measles. It had likely been in the news that there were measles cases in Texas (this is frequently disclosed for the public good to encourage vaccinations), but the nurse’s information narrows down the hospital, the general age group, and just how sick he was. Then neighbors can start thinking, “Hey, we live close to Texas Children’s and I haven’t seen Billy (totally made up name) in a while and he’s a toddler—” and then phone calls go out to Billy’s mom asking if he has measles. See?

The frightening aspect of the scenario, from a purely pediatric standpoint is, that even after seeing how sick this child was, she remained an anti-vaxxer and even mused about taking a swab from the ill child’s mouth and attempting to give wild measles to her own child! For one, I consider this child abuse. I truly cannot fathom in my mind how this nurse believes giving her child the real thing is preferred over a vaccine that can prevent the entire illness.

**The safest thing for ANY healthcare worker is to not discuss their patients at home or on social media no matter how vague they try to make the scenario.**

It is also the safest thing for authors who are writing these scenarios. As I’ve always said, you can have a character that violates HIPAA in your novel, but they must face repercussions for it. The positive side of this is that it increases the conflict in your story automatically. It also shows the reader that you’ve done your research.