Author Beware: Provider Scope of Practice (EMS)

/ Jordyn Redwood / Leave a comment

Here I am, happily reading along one of my favorite mainstream suspense authors, when a glaring medical mistake takes me right out of the story. Bummer! Now I’m wondering how long it would have taken this well known author to make one phone call to determine if this situation was plausible or not.

The scenario: The hero in our story is injured but doesn’t want to be transported by EMS to the hospital. He’s got other important things to do– like catch a killer. Awesome. EMS has him sign a release form and he’s on his way BUT the EMS team has given him an oral dose of a narcotic and two to take in the future when the pain comes back.

Did you hear that? That was steam billowing out of my ears.

This is a very common mistake authors make— issues that deal with scope of practice. I’ve blogged about it several times. This post has links to several others that just deal with scope of practice.

In simple terms, scope of practice is what a health care provider can and cannot do. EVERY licensed health care provider (a nursing assistant, a nurse, an EMT, a paramedic, a physician, a physical therapist, a pharmacist) has a scope of practice that is governed by their licensing board– whoever that might be. These governing boards determine the rules of practice. If the licensee does something outside of these rules they can be brought up on disciplinary action and even potentially lose their license. Scope of practice rules can vary from state to state.

In short– it’s bad to operate outside your scope of practice.

For instance, this document gives a pretty detailed overview of the medical treatments different EMS professionals can do.

The first problem with the author’s scenario is that EMS professionals do not carry oral narcotics to give to patients. Only IV and those that can be administered nasally.

The second problem is that EMS professionals not only operate under scope of practice laws but also medical protocols which outline the things they can do in the field and under what conditions. In fact, here’s a whole document that lists the EMS protocols for one hospital in Colorado that would give a nice overview for what likely happens in the US. There will be differences state to state but you could reasonably generalize from this.

Essentially, a paramedic giving a patient (who is refusing medical treatment) three doses of an oral narcotic (which he doesn’t carry) is a serious violation of his scope of practice. Only a few medical roles can prescribe oral narcotics and dispensing oral narcotics is the role of a pharmacist.

Authors should take scope of practice as seriously as medical professionals do because though your book might be fiction– the public will take it as fact.

Seven Medical Posts for Authors on Blood Loss and Bleeding to Death

/ Jordyn Redwood / Leave a comment

How fast a person can bleed to death is a very common question among authors and I’ve done several posts on the topic. About a month ago, I got a comment asking a variation of the question.

It’s as follows:

Although I’ve worked in an animal clinic for years, I wasn’t sure how much of what I’d seen there translated to the human side. I’m currently editing someone’s manuscript and the injuries in a couple of scenes struck me wrong enough to do some digging before revision. A couple of things I’m still looking for is how long a person remains conscious with arterial or venous bleeding (in one scene, this is from a femoral injury) and whether/how much accelerated heart rate from exertion speeds bleeding?

Jordyn Says:

It’s hard in medicine to give actual time frames. The best demonstration I ever saw of how fast it took to bleed out was from a physician that drilled a hole into a two liter bottle of pop and then squeezed it mimicking a heartbeat. He said the size of the hole could be equated with an injury to the popliteal artery (which is behind your knee) and that bottle was empty in about two minutes.

Devastating injuries to larger arteries (your aorta for instance) can cause the patient to bleed out (hemorrhage or exsanguinate) in 1-2 minutes. It’s fast. For instance, if you rupture your descending aorta in a hospital and they know exactly what is wrong with you, and even have a couple of IV’s in place, your chances of survival are still not awesome.

Some general rules:

Arterial bleeding is faster than venous bleeding. This is because the pumping action of the heart causes more brisk blood loss. That being said, all bleeding can lead to death if not controlled. It’s probably safe to assume that bleeding from an artery without any intervention could lead to unconsciousness in one to three minutes and death in under five minutes.

Uncontrolled venous bleeding might take upwards of twenty minutes or days. Again, if not controlled in any way. Again, this could be variable. The author has a lot of leeway.

Does a fast heart rate accelerate bleeding? Yes. The faster your heart beats, the more blood spills, particularly from an arterial bleed. This is a double edged sword because your body will compensate by increasing your heartbeat during blood loss to compensate for all those red blood cells on the pavement and not in your body carrying oxygen.

Here are other posts on the topic of blood loss:

Author Beware: Arteries vs. Veins.

Author Beware: Arterial Bleeding vs. Venous Bleeding.

Killing my Arteries: Truth or Die by James Patterson. Can IV drugs be given in an artery? 

Pregnant Woman Bleeding to Death.

Pregnant Woman Bleeding after Delivery.

Bleeding to death from gunshot wound to the arm and back? What organs can be hit to bleed but not be lethal?

What other questions do you have about characters bleeding to death?

Rape Kit Testing

/ Jordyn Redwood / Leave a comment

Stan Asks:

My question for you is would a rape kit routinely be used to test for evidence of chemicals found in a condom in addition to DNA or would further tests be required? My plot has a woman getting even with a man by having her girlfriend havesex with the guy (he’s using a condom). She then gives the material to her friend who applies the sperm and claimsshe was raped.



Amryn Says:

Rape kits are routinely tested for the presence of semen and sperm and maybe saliva depending on the story the victim gives. Chemicals found in spermicide and other condom components aren’t something an analyst would test for. Depending on how long of a time lapse between intercourse and the woman applying the sperm, it’s possible the spermicide on the condom would have already degraded the sperm to the point that it isn’t detectable, but that would only occur after a long time.

 More likely, when DNA testing was performed, it would yield a mixture of 3 profiles: the man, the woman’s friend, and the woman. This is because the woman’s friend’s profile would likely be present on the condom from the intercourse she had from the man. This might raise a red flag but it would be up to the investigator to look into it further.

**********************************************************************

Amryn Cross is a full-time forensic scientist and author of romantic suspense novels. Her first novel, Learning to Die, will be released in September. In her spare time, she enjoys college football, reading, watching movies, and researching her next novel. You can connect with Amryn via her website, Twitter andFacebook.

Can a Pregnant Woman be an Organ Donor?

/ Jordyn Redwood / Leave a comment

Carol Asks:

Can a pregnant woman be an organ donor?

Situation: The woman is in her first trimester. She’s been in a car accident and the pregnancy terminated itself as a result of the accident. She’s been kept alive on machines for several days with no hope of recovery. Can she donate organs?

Jordyn Says:

I don’t see why not because she’s technically not pregnant anymore. My only drawback is if law enforcement thinks the death is suspicious in any way and it becomes a corner’s case for some reason.

That being said, I do find the question intriguing– like could a pregnant woman who is further along still donate organs? My gut instinct would be that they would keep the “body” alive until the infant was viable or deliver if past 24 weeks. Then the woman should be able to donate organs.

Alleged Patient Exposure to HIV/Hepatitis After Drug Diversion

/ Jordyn Redwood / Leave a comment

I want to start this post by saying “Oops, it happened again.” The problem is, I shouldn’t have to blog about this topic considering how serious it is and the potential risk to patients.

I live in Colorado. In February, 2016, it hit the news that one of the Denver areas largest hospital, Swedish Medical Center, was testing close to three thousand patients for possible exposure to HIV and Hepatitis after a surgical tech was suspected of diverting drugs.

What is drug diversion? Drug diversion is using a narcotic for anything other than its intended use. The most mildest form is not wasting drugs properly. It requires two licensed personnel to waste a drug and sometimes you just can’t find another person at that moment and then you forget. Not excusable but understandable. The most serious form is healthcare workers using the drug themselves and not giving them to the patient or using the “waste” or overage for themselves.

The problem is, a relatively similar scenario happened at another Colorado hospital in 2008 and 2009. This was the case of Kristen Parker, a surgical tech who is currently serving a thirty year prison term for infecting three dozen patients with Hepatitis C. She was stealing unlocked Fentanyl set aside for surgery, injecting it into herself, and then drawing up saline into the same syringe where then an unsuspecting provider injected it into the patient causing transmission of the virus.

In fact, one of the anesthesiologists involved in this case went public and even wrote a novel based upon her experience. This wasn’t a quiet news story.

In this blog piece from The Daily Beast in February, 2013, Gorman states:

“At that time, we didn’t think about locking drawers,” she says. “No one ever told me I was doing anything wrong. If there were rules to enforce locking the drugs up, they were not enforced.” Rose has said it sent memos to its anesthesiologists in 2001 and again after Parker’s crime, warning them “never leave controlled substances unlocked or unattended.”

In light of this incidence, it is unbelievable to me that a case of suspected drug diversion involving a surgical tech could happen again in this state and it makes me wonder if potentially the same process of drug diversion was used as Kristen Parker employed– unsecured narcotics awaiting injection for surgical procedures.

The tech, Rocky Allen, has been arrested and has pleaded not guilty. Thus far, it appears two patients have tested positive for Hepatitis B.— although the hospital currently denies they transmitted the virus as part of this case.

So please, hospital OR’s everywhere, can we please develop a system where narcotics can be dispensed safely to surgical patients?

EMS and ER Response for an Unconscious Female Trauma Patient

/ Jordyn Redwood / Leave a comment

Ginger Asks:

I have a 23-year-old woman with an obvious head wound (she got hit with the butt of a gun, but the first responders don’t know that) who’s been outside in 20’ish degree weather without a coat for an undetermined amount of time. She’s unconscious. Obviously an IV is started, but what else will paramedics do to treat her? Warming blankets? What would happen when she got to the ER?

Jordyn Says:

Thanks for sending me your question.
 
EMS Response:

For an unconscious patient with an obvious head wound, but is unable to tell how her injury happened should be placed in C-spine precautions. That means C-collar and backboard. IV– yes. And warming. They’d get a set of vital signs, put her on a monitor and then do a full assessment to look for other injuries.

Checking her blood sugar is warranted because why is she unconscious? Did the injury to her head happen because she passed out from low blood sugar? Or is it too high? Looking for medical alert bracelets as well. They’d probably key in on a good neuro exam like are her pupils equal and reactive to light? What type of stimulation does she respond to (voice, touch or pain?) They might even give a dose of Narcan to rule out opiate overdose (like heroin.)  


In the ER:

Full assessment as above and we’ll look for other injures. We’ll maintain C-spine precautions. She would be completely undressed (again– looking for other injuries.) We have a better ability to monitor temperature so we’ll know exactly where she’s at and work to rewarm her. This could range from warm blankets to warming lights and heated IV fluids. Full set of vital signs. We’d place her on the monitor as well to watch her HR, breathing and oxygen levels continuously.
 
As far as testing and procedures go, if she remains unconscious, I would say the following:

1. Spine X-rays. 
2. CT of the head (to look for bleeding, stroke, tumor.)
3. Labs: Full metabolic panel (this will check blood sugar again), complete blood counts, alcohol level, aspirin level, Tylenol level. Tylenol and aspirin are drugs people will overdose on that can be very serious.
4. Urine toxicology panel (this would pick up on major substances of abuse but not everything.) Also urine pregnancy test. 
5. ECG. To see if a heart arrhythmia or heart attack could be an explanation for her passing out.
 
Unless we know the exact mechanism of the injury we have to consider both inflicted wounds from another person but also that she might have just passed out and hit her head and what the reason for that might be.

If she’s truly unconscious and doesn’t respond to pain– she’d likely get a tube in every orifice as they say and they’d have to consider whether or not to intubate her (put a breathing tube in) to protect her airway. If that happens, then NG tube (placed probably through the mouth into the stomach) and a Foley catheter which drains your urine into a bag.

If she’s somewhat responsive but immediately drifts off– they could hold off on tube placements, check the tests I’ve listed, and give her some time to see if she wakes up on her own if she’s breathing well on her own.

Surviving a Shipwreck Post Hurricane

/ Jordyn Redwood / Leave a comment

Jocelyn Asks:

I’ve written a hurricane scene, and I don’t think I got the medical details right, so I thought I should check with you.

I have characters abandon their ship as it goes down. They stay afloat using planks of wood, but just holding on to them in the water, not lying on top of them. This takes place in the Gulf of Mexico in September.

When they are rescued several hours later, what will their condition be? Will they be fully conscious? Would they be cold? My heroine’s brother dies in the water, so is that enough to put her into shock, along with the ordeal of surviving the hurricane?

While one character is floating in the water, a piece of bowsprit breaks off from another ship and flies through the air, hitting him. I want to injure him enough for him to lose his grip on the plank he’d been holding onto, but I don’t want him to die from this injury. I was thinking if the wood hits him in the arm or shoulder, either breaking his arm or dislocating his shoulder, that would be good enough. Is that realistic though? Or does it just depend on the angle and the velocity?

Jordyn Says:

First thing to determine is the temperature of the water in the Gulf of Mexico in September. I found a table from the National Oceanic and Atmospheric Administration with water temperature tables for the Gulf of Mexico  that lists temperatures for September in the mid to upper 80s.

The next question is how long does it take hypothermia to set in when you’re submerged in water at this temperature?

This table gives an “indefinite” time frame where as it lists time limits for cooler water temperatures. For instance, in water that is 32.5 degrees, it gives a time of under fifteen minutes for exhaustion or unconsciousness to set in.

Considering this information, your characters should be conscious when they are rescued. Just because they don’t die from hypothermia doesn’t mean there aren’t other risk factors like getting eaten by ocean creatures, sheer exhaustion, or dehydration and malnourishment from not eating or drinking.

If the rescue is under twelve hours, I’d imagine they would be in pretty good shape. An adult can probably survive three days without water but it would also depend on what environmental factors are present. You’ll dehydrate faster in sunny weather than a cool, overcast day. I would imagine they would still feel cold. Your normal body temperature is 98.6. Hot bath water ranges from 99-104 degrees. Bathwater temperatures vary depending on the source and hot tubs are around 104 degrees. So, being immersed in 80 degree water will still feel cool. Patients getting room temperature IV fluids always get chilly.

Emotional traumas like the death of a loved one AND surviving a cataclysmic weather event can put someone into shock.

I think it’s reasonable to give your character a fracture after being hit by the bowsprint. But then he’d be unlikely to use that arm at all to hold onto things but it should be a survivable injury if a closed fracture and the rescue is fairly soon. I would think an open fracture, where the bone comes through the skin, would put him more at risk for complications and lower his survivability if the rescue is delayed by a few days or more. 

In What Form are X-rays Read?

/ Jordyn Redwood / Leave a comment

Dawn asks:

Are x-rays still on film and put into a light box? Or are they digital, on a computer screen.

Jordyn says:

Yes, x-rays are digital now and viewed on computer screen. Paper print outs and discs are given to the family. Paper copy if it’s just showing the parent “this is your kid’s fracture.” A disc if another doctor will need to look at it. Even when we get films from other area hospitals they are on a disc. I haven’t seen films in close to ten years.

If the novel is set in the US this is probably a safe assumption but may not be for developing countries.

What’s The Ruckus About Zika?

/ Jordyn Redwood / Leave a comment

If you’ve listened at all to the news lately then you’ve been hearing about Zika virus and the concern it’s causing about a possible link to microcephaly (babies born with small brains) from women who were infected during their pregnancy. I knew it was time to blog about Zika when I overheard another woman at the salon claiming that engineered mosquitoes were responsible for the Zika outbreak. Surely, this was a conspiracy theory but my suspense author brain was warmed up and not just because I was under a set of heat lamps.

I had to investigate (and make lots of notes for future books.)

Zika is a flaviviridae and is in the same family as Dengue, West-nile virus, and Hepatitis C. Zika is transmitted via mosquitoes so an infected person gets bit, and when that same mosquito bites another person, transmission can occur. 
Only about twenty percent of people infected with the virus will show symptoms. It’s unknown how long the incubation period is. An incubation period is from the time of infection until you show symptoms. 
Symptoms can include fever, rash, joint pain, headache and conjunctivitis lasting up to one week. Deaths related to Zika virus are rare. 
There is no current treatment for Zika other than prevention– which in this case is not getting bit by an infected mosquito. So repellent, mosquito nets, etc. The above information comes from the CDC website which you can further read here. 
 Zika was first discovered in 1947 in a Rhesus monkey in Zika Forest, Uganda. There have been previous cases in Uganda, Tanzania, and Nigeria before it broke free from Africa into other areas. It hit Chile in 2014 with cases until June 2014. And then it disappeared.

In May, 2015, Zika was confirmed in Brazil. The largest concern is Zika infection in pregnant women where it seemingly is causing arrested brain development in unborn babies or microcephaly. It’s unknown what percentage of infants, if any, develop microcephaly when the mother is infected with Zika during her pregnancy or at what point in the pregnancy this would be concerning for developing the congenital condition.

Brazil is where there was a noted spike in cases of microcephaly. Keep in mind, the link between Zika and this birth defect is suspected but scientifically unconfirmed. Some are postulating that the increased cases are due to hypervigilance and a broad screening net. The Brazilian government stated on January 27th “that of 4,180 cases of microcephaly recorded since October, it has so far confirmed 270 and rejected 462 as false diagnoses.”    

And, according to this well laid out article, the genetically engineered mosquitoes aren’t the cause for the spread of Zika. However, I do see the possibility of a future post and a very good basis for a medical thriller in the future.

What do you think about Zika? Are you worried about it? 

How Likely Is It For A Parent To Be an HLA Donor Match for Bone Marrow?

/ Jordyn Redwood / Leave a comment

Anonymous Asks:

How likely is it for a mother and an uncle to be bone marrow donor for her child? What can a donor expect if picked for donation?

Jordyn Says:

I found this article you might want to take a look at that specifically talks about the odds of a person being a match for their child. A sibling has the best chance at twenty-five percent. A parent of a child only has a one in 200 chance to be a match. Why is that? Because a child gets genetic information from two parents and it’s unlikely that these parents would have the same genetic makeup as their child. So the likelihood of both the mother and a biologically related uncle coming up a match would be pretty slim. I think both being a full match isn’t possible statistically.

This article goes into detail about what a donor can expect.