Medical Errors in Manuscripts: People on a Vent Cannot Speak

/ Jordyn Redwood / 5 Comments

Last post I posed a medical question. Why are there white stripes on IV catheters? Answer: If the catheter is lost in the patient, you can find it on x-ray.

Now for another common medical error seen mostly on television and at times in works of fiction.

Note to writers everywhere: Intubated people (those that are on a breathing machine) cannot talk or even moan.

I’ll start by covering the basics. The sound of talking (and other noises) is made when you pass air through your vocal cords causing them to vibrate. This is what your vocal cords look like.

Jeffbrent/Photobucket

When a patient is intubated, a large plastic tube called an endotracheal tube (ETT) is passed down the throat, through the vocal cords, and into the trachea. The end of the ETT should sit slightly above the carina. The carina is the bifurcation, or splitting, of your trachea into the right and left lung. The ETT is positioned there so both of the lungs get ventilated or inflated with oxygen.

This is what an endotracheal tube looks like.

Adventures of a Respiratory Care Student/Photobucket

When the ETT is fitted correctly, a person should not be able to make noise because air is not passing through their vocal cords, it’s passing through the tube. In an adult, the balloon at the end of the tube is inflated so that it fits snug inside the trachea. If we hear an intubated person speaking or moaning, we know that air is passing through the vocal cords again and something is wrong with the ETT.

It could be as simple as the balloon or “cuff” needing to be inflated with a little more air so it fits snug again. It could be as complicated as the patient has become extubated—meaning the ETT is no longer in the trachea and you go in the room and find the patient holding the tube in their hand.

Medical question for you: How are intubated patients kept from extubating themselves?

Medical Errors in Manuscripts: An IV is not a Needle

/ Jordyn Redwood / 8 Comments

This week I’m going to cover three of the most common medical errors I see in manuscripts.

Note to authors everywhere: An IV is not a needle.

Product Photo

This picture is the IV as it comes out of the package. This is an over-the-needle catheter meaning the needle is encased inside the catheter. Once the needle is inside the vein, the white button (seen at the base of the blue part) is pushed and the needle is sheathed inside the bottom plastic holder. You can see the spring fills that compartment in comparison to when the needle is visible. This is a safety feature to prevent needle stick injury. Once the needle is gone, a small plastic catheter is left inside the vein. Not a needle. The needle is gone.

When you start an IV you get a “flashback”— meaning blood is visible in the catheter. Typically, once you get flashback, you advance the catheter and needle a little more (like one millimeter) into the vein. Then you’ll slide the catheter off the needle and advance it into the vein, popping the button to sheath the needle. Then you connect tubing or a cap to the yellow portion and you now have IV (intravenous) access.

Needle recapping is a no-no in the medical setting. Every healthcare provider is drilled to never recap needles. Many devices have safety features like this one so you don’t have to recap to cover the needle.

Did you know the hubs of IV catheters are color coded for size even across different brands? For instance, a yellow hub is a 24 Gauge catheter. And catheter sizes are inverse so the smaller the number, the larger the IV catheter is. A 24 Gauge would be the size for an infant versus an 18 Gauge would be the size for an adult patient.

Medical question for you: Why are there white stripes on the plastic catheter (the part that stays inside the patient)?

What Does a Nurse Do? Part 3/3

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This week, we’ve been examining the role of the nurse at the beside. Thus far, we’ve looked at the nurse as advocate and safety net. Let’s look at the nurse/physician relationship.

Here is Part I and Part II.

I work in an emergency department. I would say that I have a symbiotic relationship with the on duty physician. One cannot survive without the other. For instance, say there aren’t any nurses to staff the ED. How well do you think that one physician could provide medical care? What if the physician falls ill? Can the nurses provide medical care? What is the difference?

A physician’s role is to diagnose illness and determine the course of treatment. A nurse’s role is to initiate the medical plan of care, monitor the patient’s response to that medical plan, and educate the patient and family regarding their illness. You can see, one without the other and the ER comes to a halt.

Can a nurse refuse to carry out a physician’s order? Let’s look at one hypothetical example: A physician orders morphine for a child at ten times the normal dose. This is clearly dangerous and could kill the patient. What would a nurse do? First, I would have a conversation with the physician about the order. I would state my concerns and the physician will likely change the order. If that doesn’t work, I would approach another physician with my concerns to see if I can get an ally in re-approaching the ordering doctor. Some professionals will better handle being questioned by a peer vs. who they might consider a subordinate. Regardless of my view of having a symbiotic relationship with the physician, some doctors do view the nurse as a subordinate to just carry out the orders as written. This is becoming more rare. If that doctor to doctor talk doesn’t work, then I would call my nurse manager. If the nurse manager agrees the situation is dangerous, she can begin to pull in the medical director who can address the issue.

Say the order isn’t dangerous but I don’t want to initiate the order. Some medications are dangerous for a pregnant nurse to give but are fine for a non-pregnant patient to receive. If I was pregnant and didn’t want to give the drug for that reason, I would ask another nurse or the physician to do it.

What if the nurse has a conscious objection? What can she do then? Thoughts?

What Does a Nurse Do? Part 2/3

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Let’s continue our discussion of what a nurse’s role really is and how you can use this to increase conflict in your manuscript.

You can find Part I here.

Last post we looked at the nurse as patient advocate. This post, we’ll look at the nurse german-shepherd-puppyas the patient’s safety net. Which dog would you rather have defending your house? The cute, furry puppy or the grown dog with the watchful eye? A strong nurse is the patient’s watchdog. I look out for my patient’s interests when they may not be able to do so.

I  am often the last line of defense between everything and the patient. Let’s delve into the medication arena. The nurse gives the patient’s medications. It’s my job to ensure that what the physician orders is the correct medication for the illness, for the right patient at the right dose given the right route (by mouth, intravenously, etc…). One of the challenges in pediatrics is there is no standard dose. Every drug dose is based on the patient’s weight. I’m not going to give the same amount of morphine to a 5kg infant vs. an 80kg teen. If the patient is not weighed or their weight is entered incorrectly, this can have disastrous effects when medications are given.

german-shepherd-578929_1920Medication errors do happen. I want to reassure you that there are a lot of safeguards in place to prevent such occurrences. Most departments are going to computer based medication ordering. This is beneficial in many ways. One, the order is typed and therefore easily read eliminating mistakes in reading handwriting. Second, most medication based ordering systems have built in safeguards that will check the prescribed dose against the patient’s weight to make sure the dose is not too high. In pediatrics specifically, all high risk medications are double checked by another nurse and co-signed on the chart. But as a good nurse functions as a safety net, so should the parent question what is being given to their child and why.

Let’s take a real life example. During my years in the pediatric ICU, I worked at a teaching hospital. At this particular institution, residents could rotate through the unit their second year. I had a second year resident order potassium, which is a potent electrolyte, at four times the recommended dose. Now, if too much potassium is given, it will cause the heart to stop beating. That’s how big this error could have been.

I approached the resident and questioned the order. He stated, “But the drug book says to give 4meq/kg/day.”  I explained that the “per/day” was the key term. That the drug should be divided into four doses given every six hours, no more than 1meq/kg at one time. I told him he could order it that way, but the pharmacy wouldn’t fill it and I certainly wouldn’t give it.

Needless to say he changed the order and the drug was given correctly.

Have you ever had a medication error happen to you? How do you think it could have been prevented?

What Does A Nurse Do? Part 1/3

/ Jordyn Redwood / 2 Comments

I still find it interesting that many outside of healthcare don’t truly understand what a nurse does. Television, movies, and fiction all have varying takes on the subject– most of which don’t depict reality.

teen-girlWhat is your definition of a nurse? When you’re in contact with the medical system, what do you want a nurse to do for you? I would love to know.

My ultimate role as a nurse is to serve as an advocate for my patients. In pediatrics, that means my clients range from a newly born infant to a young adult who is most often accompanied by a parent. How can this be a source of conflict? Let’s take a look at an example of how my advocating for a child can become a source of conflict between me and the parent.

A parent presents with her teen daughter and wants her tested for drugs. The mother has concerns that her child may be experimenting and wants confirmation. Can we run a drug test that covers common drugs of abuse? Yes. Will we in this situation? Depends.

How are we going to obtain the urine specimen if the teen is not a willing participant? We would have to hold her down, pull her legs apart, and insert a catheter into her bladder. Legally, this would likely be considered assault if the teen is not having a medical emergency. A medical emergency would be something dramatic– like no pulse and no breathing. Or, the patient is unconscious and we’re trying to determine why. In this situation, the teen is not experiencing a medical emergency. The teen is awake, alert, and communicating appropriately. As a nurse, I am not going to do that to her regardless of the parent’s demands.

What are the options?

First, the physician will have a conversation with the parent and child to discern the parent’s concern. The child will be interviewed alone and asked pointed questions about their drug use. The parent may also be interviewed alone as well. The first issue is to figure out if there is a legitimate concern. If there is, will the teen willingly submit to the drug test? If so, we’ll run the drug screen. If not, in a non-emergency situation, the approach will likely be to get the family into some counseling.

However, if we do drug test the teen, we may or may not disclose the results to the parent. Whether or not this information would be released depends on the state and the age of the child.

How has a nurse advocated for you?

SNAPPs are Killing Superbugs

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Few things strike the same added fear in both patients and medical providers like superbugs. What are these pesky little creatures? Put simply, they are bacteria that have become resistant to several, if not all, antibiotics. As recently as October 2, 2016, CNBC’s web site posted an article discussing the threat of these superbugs.

monster-426996_1920This is very personal to me as both my grandfather and father-in-law died from one of these infections. The CDC’s website states “at least two million people become infected with bacteria that are resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections.” These super bacteria go by the names of MRSA, CRE, and VRE. You can look here to find the bacteria threat level of these bugs as laid out by the CDC.

Even more worrisome is the fact that a forty-nine-year-old woman from Pennsylvania was found to have Colistin resistant E. coli in her urine. Colistin is considered the drug of last resort for different types of superbug infections.

All that could change if Shu Lam, a twenty-five-year-old PhD student from the University of Melbourne, has anything to do with it. She’s created a polymer (like a ninja killing star) that is annihilating these superbugs without the use of antibiotics and doing it very successfully by tearing open the cell wall of the bacteria that then initiates a death spiral in the bacteria itself.

I am giving her a standing ovation. Strong work!

Thus far, the polymer has only worked in a petri dish against six strains and one superbug in live mice. What’s good news even about this is that so far the bacteria haven’t become resistant to the polymer.

The polymers are called SNAPPs (structurally nanoengineered antimicrobial peptide polymers). The theory behind their highly successful kill rate is that they completely destroy all the bacteria. What typically happens in drug resistance is the few bacteria that survive the antibiotic go on to propagate little tiny soldiers with some new weaponry– leading to drug resistance. And, even better, SNAPPs don’t affect healthy cells due to their size. Click this link for a photo of the SNAPPs at work.

SNAPPs are Killing Superbugs. Click here to tweet.

I’ll be keeping my fingers crossed that Shu Lam’s SNAPPs make it to human trials and become as successful in treating serious bacterial infections as they have in the lab. The amount of lives that could be saved would be staggering.

To learn more about Shu Lam click here.

What are SNAPPs and how are they killing drug resistant bacteria? Click here to tweet.

Autumn Is Here!

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Autumn is a time of change. Anyone who knows me knows that fall is my favorite time of year. There’s really not much to love about it. Pumpkin Spice everything (you’re safe here my pumpkin spice friends!) Caramel apples. Cooler weather. Sweater time!

fall-1432252_1920Plus, there’s all things spooky and scary. Perfect time of year for a suspense author. Who’s watching the new television show The Exorcist? Me? Of course!

This is my first official WordPress post for Redwood’s Medical Edge and I’m super excited to be here. Thanks to everyone that followed me from Blogger– I really appreciate it!

Some of my earliest posts didn’t transfer from Blogger (which, shockingly, some of you may not have seen!) I’ll be blogging more frequently to pull some of these posts from Blogger as well as great new content and having some of my super awesome author friends stop by as well. There’s going to be a lot of giveaways– particularly before the end of the year– so be sure to subscribe to these posts as that’s one of the easiest ways to be eligible for prizes.

I’ll also be focusing more on my author newsletter (sign up here!) and my new secret street team, Jordyn Redwood’s Forest, as a way to interact more personally with readers. Want free copies of my books before anyone else? Want to help me develop new stories? The street team is where you need to be. There will be exclusive content only in my newsletter so be sure to sign up!

Happy Fall!

Jordyn

Is a Patient With a Concussion Admitted to the Hospital?

/ Jordyn Redwood / 3 Comments

Recently, I finished a book that included the following medical scenario. The main character fell into a river and suffered a broken arm and concussion. During her ER visit, the doctor tells her she needs to be admitted overnight for observation because of the concussion.

This is a common medical myth (along with the one that a CT scan is required in all instances of head injury– it’s not.)

A simple concussion does not need an overnight hospital stay. Let me qualify what I mean by simple. You receive a hit on the head and have one or some of the following global symptoms (dizziness, headache, nausea, vomiting, and amnesia to the events.) Global symptoms mean more than just the bump on your head hurts.

This is really how concussion is diagnosed. CT scan is reserved for concerns of bleeding and/or fracture that might require a neurosurgical intervention. Typically, symptoms associated with bleeding and fracture are persistent and more dramatic. Headache pain is not relieved with medication and/or worsens. There is more than one episode of vomiting. Persistent confusion. Perseverating– saying the same thing over and over. Inability to move part of the body. Decreased responsiveness. Amnesia that doesn’t improve.

A patient with a simple concussion is monitored in the ER for several hours. Typically, we’ll give them medication based on their symptoms to see if they improve. For instance, a patient that has nausea, headache and dizziness will get an anti-nausea medication and an over-the-counter pain reliever like Tylenol or Ibuprofen. If their symptoms improve and/or resolve and they can hold something down to eat then they are discharged home with instructions on when to return to the ER.

In order to be admitted into the hospital the patient must exhibit severe, persistent symptomology and/or have bleeding and/or fracture.

In absence of these, the patient will be discharged home.

Castle: Dying From Medical Inaccuracy

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Personally, I loved the show Castle. Sadly, it’s been cancelled and perhaps it’s for the best– especially if Season 8, Episode 21 entitled Hell to Pay is any indication of the attention to detail they were giving their medical/forensic scenarios.

The following is the assessment medical examiner, Lanie Parish, gave concerning New York’s latest murder victim.

“He bled to death from a wound in his left side. My guess is whatever he was stabbed with punctured his subclavian artery. After that he would have had about thirty minutes to an hour tops.”

There are TWO major problems with the above assessment.

First, your right and left subclavian arteries are located just below your collar bones. So, if you’re stabbed in the left side, it’s really hard to hit that sucker. That got me thinking about what is on your left side that could cause brisk bleeding. Your spleen is located on your left side tucked pretty nicely under your lower left ribs. Perhaps they meant splenic artery which would have been appropriate for the scenario.

Second is the time frame. If you have a severed artery, the bleeding will be severe and deadly if not controlled in a matter of minutes. There is no way this character would have survived thirty to sixty minutes– I’d give max time at ten minutes and that might be pretty generous.

So Castle, at least go out on a high note with a medically accurate death scenario.

Author Beware: The Right Patient Placement

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Coming across inaccurate medical scenarios in books is common for me so to have one raise my ire enough to blog about it generally means a pretty big eye roll was involved when I read the passage.

Scenario: An elderly male dressed in sweats is found wandering the streets of New York in a confused state.

The author’s solution: The police take him to a nursing home.

Well, yea, just— no.

If police find an elderly male, let alone any confused individual, wandering the streets without any ID the first place that person is going is straight to the ER likely via ambulance.

The reason? One, is to make sure nothing medically is wrong. Chronic diseases such as dementia and Alzheimer’s are not the only reason the elderly people become confused. Something as simple as an electrolyte imbalance could be the cause. In any new onset confused state, other minor and major medical conditions need to be ruled out first. What might some of those be? Electrolyte imbalance. Brain Tumor. Stroke. Head Injury. Brain Bleed.

Secondly, there is not a nursing home in the United States that will take in an elderly person unknown to them without a medical evaluation first. Plus, do you know all that’s involved for nursing home admissions? A lot.

In this instance, if the patient is deemed to not have anything clearly medical (that could be fixed or treated) causing his confusion, then the hospital would involve the police and likely social services for placement.

But no drive by drop-offs at the nursing home.