Someone Please Rescue 911: Teach Them to do CPR Correctly

I’ve been teaching CPR for almost thirty years. Can you believe that? I hardly can.

I’m pretty passionate about CPR because time after time studies have shown that this is the patient’s best path for survival— high quality CPR given as soon as the patient needs it. It’s not rocket science and it’s pretty easy to research. Here’s a Google link to a bunch of images that show the algorithm for CPR.

What you want to be sure of is that you’re using the most recent guidelines. For the American Heart Association (AHA), their most recent set came out in 2015. The AHA reevaluates their CPR guidelines based on research every five years. Next update will probably happen next year, but the educational materials likely wouldn’t be released until 2020.

In episode nine of this season’s 911, Hen and Howie rescue a boy from a submerged vehicle. He is unresponsive and pulseless once he reaches the shore. They begin CPR (just compressions) and after every set of compressions they do a pulse check. After about a minute, they revive the patient.

Did you know that even healthcare providers are not that great at determining whether or not there is a pulse? It’s true. On top of that, imagine trying to do a pulse check with cold hands, in the dark, in the rain. Not easy to be sure.

The reason the pulse shouldn’t be checked that much is that it ultimately delays compressions and we don’t want to do that. Every time compressions are stopped, the blood perfusion to the heart also stops and it takes several compressions to reperfuse the heart. Some fire departments have gone to doing two hundred uninterrupted compressions for this very reason.

In lieu of this issue, I did like this episode quite a bit. It’s Hen’s origin story and I do think it highlighted some of the issues minorities face in the fire service.

911— let’s just stop messing up the little things.

New Amsterdam and The Law: Real or Not Real?

In Episode Two of the new NBC show New Amsterdam, there are some pretty amazing claims about two specific laws. Keep in mind, I’m not a lawyer, and this blog is for fiction writers so you might be interested in doing your own research, but these are my thoughts on these “two laws”.

Law #1: In one scene, a man is standing outside his room complaining that he must choose between his wife’s care and a car— eluding to how expensive the medical care will be and that the hospital won’t tell him how much it is. Dr. Goodwin says in passing, “Congress actually made it illegal for hospitals to disclose prices to you.”

Having worked in health care for twenty-five years, I understand how frustrating this can be and there definitely needs to be reform in this area. However, let me give some insight into why it is hard for hospitals to give you an exact price up front. Simply, humans are not machines and often do not medically act the same in every situation.

Let’s say your child comes in for stitches and we tell you it costs “X” amount. This assumes your child only needs a topical numbing agent for the procedure. However, your child is not on board with the medical plan and won’t hold still for his stiches so a decision is made to give them some sedation— and the topical medication isn’t enough to numb the site so we then have to inject a medication. Since the child received sedation, now there’s increased monitoring time to make sure the child is okay to be discharged home. Things like this happen every day in healthcare.

The problem is when you quote someone a price, they want to (rightly so) hold you to it. When you can’t, then it creates dissatisfaction for both the patient/family and the hospital.

Despite this, I could not find any such law that congress has passed that prohibits a hospital from disclosing prices. I think the reluctance is on the side of the hospital for the reasons I mentioned above. In fact, there seems to be movement legislative wise, in the other direction for more transparency. You can read the American Hospital Associations thoughts on it here.

Law #2: A young boy is brought in for psychiatric treatment and the psychologist on staff believes he’s being overmedicated and wants to wean him off all his meds. Quick note on that— not sure why a neurologist would be involved in this process. A psychiatrist, yes.

There’s a statement made regarding the Prohibition of Mandatory Medication Amendment of 2004. As from the link, this law does exist. Put very simply, a school cannot force a child to take medication to receive educational services. However, in the show, it’s stated that the school can force a child to take meds for educations purposes if the mother has signed an IEP otherwise known as an individualized education plan.

I could not find any source to support this statement. This blog post written by a mom who seems familiar with this issue would be a good one to read. Do I believe that schools try to “strongly suggest” that kids are medicated. Yes, I do. However, I don’t think it’s supported by law.

New Amsterdam: Prioritizing Epinephrine Over Oxygen

New Amsterdam is a new medical drama on NBC this year. You can see my first post about it here. Today, I wanted to review a medical scenario with you and the problems with they way it’s presented.

As I discuss the scenario remember that all medical providers are taught this from the very moment they step into medicine: A, B, C— Airway, Breathing, Circulation.

Here’s the setup: A man travels from Liberia where he begins to exhibit signs of Ebola. They place him in isolation (a good move). A big lecture is given by Dr. Max Goodwin, the new medical director, that no one is EVER to enter the isolation room without the proper PPE (Personal Protective Equipment). From there, it gets a little bit strange.

The first issue is that it’s stated that the isolation room is “stocked with every available medication should the patient need to self medicate.” A few problems. A sick and deteriorating patient is going to have the wherewithal to find a drug and give it to himself? This is later proven to be a bad idea when the patient can’t even reach for an easily accessible oxygen mask without falling out of bad.

Also, everything in the isolation room is going to get thrown out and likely charged to the patient so for a medical director who is so concerned about minimizing costs for the patient . . . well, you can see where I’m going with this.

The patient begins to cough up blood, bleeding profusely from his mouth, and has difficulty breathing. As the doctor is getting into her PPE, she instructs him to give himself oxygen which he is unable to do and then falls out of bad. Without getting into full PPE, she enters the room to help.

I actually like this aspect of the show. As I’ve said all along, medical people can make bad choices, as long as the writer shows repercussions for them which they do in the show.

The doctor immediately begins to work to aid his breathing. This is the right choice. She believes the airway is too obstructed so she immediately moves to a needle cricothyrotomy. This is generally done as a rescue measure when other attempts to secure an airway have failed— it is not the first choice.

However, as the doctor inside the isolation room is generally doing most of the right things, Dr. Goodwin (the new medical director) is telling her to give the patient an IV dose of Epinephrine before she gives him oxygen. He tells her to prioritize the epinephrine over the oxygen. At the screen shot to the right, what’s obvious is that the blood pressure (82/40) is low and that the patient’s oxygen levels are REALLY low at 64% (normal is generally considered above 90%).

There really isn’t an indication for epi IV (as in a code dose) in this scenario. The first two reasonable thoughts for this patient’s low blood pressure are sepsis (low blood pressure caused by overwhelming infection) and blood loss from the obvious hemorrhage. Epi can be given in this situation (for low blood pressure related to sepsis) as a continuous drip, but not as a push medication.

Most importantly in this situation, epi would not be prioritized over the patient’s alarmingly low oxygen levels.

New Amsterdam: A Problem with Repetition

For you, my faithful reader, I took in the latest foray into the medical drama by watching New Amsterdam. I was hesitant because of being burned recently by The Good Doctor and The Resident. I know, some of you are loving those two shows, but let’s try to be somewhat medically accurate if you’re going to write a medical drama.

Anyway, I decided to give New Amsterdam a try. It stars Ryan Eggold as bright and shiny new medical director, Max Goodwin, at the healm of a safety net hospital called New Amsterdam. He’s a flawed character, which I liked, and he’s in charge of a staff where they’ve had a new medical director every year for the last five years.

Of course, his moral center is to upend the system for the benefit of patients and not necessarily the gain of money. This is in itself strange since they make it a point to say this is a public service hospital— which still needs to worry about money— but the feeling is different than working at a for profit hospital.

To carry through his moral center, he needs to make big changes fast. I’ll step through some of what I found problematic with the first episode, but I was intrigued enough to keep watching so I’ll keep you posted.

Problem One: One of his first acts as medical director is to fire the entire cardiothoracic surgical team— like every. single. one. Put aside that generally there are a lot of hoops to go through when firing anyone, particularly a doctor, this action puts the hospital at risk of not being able to serve the people he wants so desperately to save. Level I trauma centers must meet certain requirements in order to keep their doors open and firing the entire cardiothoracic surgical team is going to put this in significant jeopardy.

Problem Two: Committing a patient to inpatient psychiatric treatment to keep her out of foster care. Again, as with my recent post on the movie Unsane, there are strict laws on how long you can involuntarily commit someone and generally it needs to be reevaluated on a weekly basis. So, though commendable (because she does like the staff where she is and it would keep her safer than where she’s been), it’s just not feasible that any scenario like this would ever pan out.

Problem Three: Saying the same thing, but fancier. Sometimes I wonder who they find to be medical consultants for these shows. There must be someone. Then I wonder who this someone is and what is the nature of their medical background. In two different areas of the show, the doctor is basically saying the same thing.

Here are two examples:

1. “The patient got diazepam and Valium.” Okay, awesome. These are exactly the same medication. So, you gave the same drug twice?

2. This is a set of orders given by an ER physician. “I need a CBC, BMP, Chem 7 and a saline lock.” Sweet! A CBC is a complete blood count, however a BMP (basic metabolic panel) and a Chem 7 are the same test.

Overall, an intriguing show and I’ll give it another try, but I’m also available for medical consulting!

The Movie Unsane is Insane in its Portrayal of Mental Health Care

A recently released movie, Unsane, starring the remarkable Claire Foy, highlights the plight of Sawyer Valentini after she’s been involuntarily committed into an inpatient psychiatric hospital.

This post does contain spoilers to the movie so stop reading if you don’t want to know more about the film.

The crux of the story is that Sawyer believes her stalker has made his way into the psychiatric unit where she is a patient— whether or not that is the case is the mystery.

Unfortunately, the way that psychiatric care is highlighted in the film is disturbing at best. At worst, I hope it doesn’t deter anyone from seeking mental health treatment if they need it.

Problem One: Not disclosing to a patient why she’s being admitted. The genesis of Sawyer’s admission into the psychiatric unit stems from a visit with a counselor where she discloses at times she thinks about hurting herself. She’s left unattended (a no-no if you think someone is suicidal) and the next scene is a nurse escorting her into an intake room. The nurse never fully explains to the patient the reason for the admission and leaving it out doesn’t really increase the drama of the scene— it just makes the nurse look mean and uncaring. Simply, a nurse could say, “Your mental health provider has placed you on an involuntary hold because she’s concerned you’re going to hurt yourself. ” Then the heroine can argue with her about why she feels the admission is unnecessary.

Problem Two: Having the patient undress but allowing her to keep her bra. A bra is considered a ligature risk and patients can’t have anything on their person that they might use to hurt themselves. Hair ties, piercings, and other jewelry are all removed.

Problem Three: Drug injection sites. Emergency drugs for agitated patients are usually given IM (intramuscular) and not IV (intravenous) to the neck or arm. Can you imagine trying to start an IV on an agitated patient? It’s much easier to land a needle in a large muscle group then to try and finesse a tiny IV catheter into a moving target.

Problem Four: Leaving a patient alone in restraints all night. There are very specific regulations around restraints and significant documentation that goes along with it. Patients in restraints are continuously observed by a staff member and circulation to their extremities is checked often. Also, the patient must be offered bathroom breaks at a minimum of every two hours and you can’t deny them food as punishment. The goal is always to get patients out of restraints as soon as they can be safe— and that doesn’t always imply that they are calm.

Problem Five: A mixed gender open unit. Need I say more?

Problem Six: That psychiatric care is an insurance scheme for money and that patients are intentionally kept until their insurance money is exhausted. This is a large crux of the movie to the point that one of the patients is actually an undercover police officer trying to uncover the scam. This is the most disappointing aspect of the film. There are so few mental health beds around the country right now that it is not difficult to fill them. Here’s a news article here, here, here, and here— which all posted within one week. Trust me, mental health facilities can keep their beds full without perpetuating insurance schemes.

Overall, an interesting movie, but portraying the current state of mental health care in this country would have only increased the tension and drama for this film.

Video on Treatment of Excessive Bleeding

Since I get LOTS of questions regarding bleeding, I thought this would be a nice instructional video to post regarding treatment of excessive bleeding.

The post is mildly political at the beginning and does contain some profanity (bleeped out), but at the end it is a great discussion of controlling bleeding— particularly use of tourniquets.

Thanks ZDogg, MD for the great information and keep up the good fight.

911: Let’s Provide Some Medical Care

In the Season Two/Episode Eight airing of the FOX television show 911— there was a great scene on how to really provide no medical care.

The setup: A gay couple is getting ready to go on a bike ride. Much time is spent in a musical montage showing their lives together. It’s clear they have had a loving relationship and remain deeply in love. One gentlemen goes to load a bike onto a SUV when, in a series of unfortunate events, he gets pinned by the SUV to the entrance gate— akin to Anton Yelchin’s accident (though they do show in the episode the SUV was placed in neutral).

He is discovered by his partner who then calls 911. Upon arrival, there isn’t much done for his lover. He is essentially declared dead on arrival.

Then, the gentleman who discovered his partner, goes unconscious while a firefighter has his back turned. Literally only a few seconds have expired when the firefighter discovers he’s passed out. They provide one and a half cycles of CPR and kind of shrug their shoulders declaring that he’s died, too.

This is unacceptable management of this patient. It’s essentially a witnessed arrest so they were correct to start CPR immediately, but at the very least, he should have been connected to an AED for rhythm analysis and probable defibrillation. A very common reason for sudden collapse are arrhythmias that will respond to electricity. There’s no reason why this gentleman’s treatment  should have been so sparse. It would have increased the drama and the tension of the episode to have this patient get a full resuscitation.