Author Question: Drug Injection Scene

Kiri Asks:

I really hope you can help me. I feel like I’ve reached out to half the medical community and still haven’t gotten an answer.

I have a protagonist who suffered a ruptured aneurysm two years before the story starts. The aneurysm caused a stroke. Presently, he is mostly recovered, though he still suffers migraines and some memory loss. I have a scene where another character catches sight of yet another character giving my protagonist a shot in the arm.

Originally, I had the intramuscular injection be a vasopressor to help with his blood pressure, but then someone told me this would only be done in a hospital.

I would really like to keep this injection scene. So I changed it to an anticoagulant, though I’m having trouble verifying that this is anything someone like him might need. (Did I mention he has another blood vessel wall bulging and ready to burst, this one inoperable?)

I also have him taking beta blockers for his migraines and he later uses these to try to commit suicide by taking an entire bottle. An ER nurse told me this would certainly be dangerous. I could change it to another drug.

Any thoughts are much appreciated.

Jordyn Says:

First of all, you have two competing medications. A vasopressor raises blood pressure and are typically given IV in the ER and ICU setting. The beta blocker used for his migraines can (and often does) lower blood pressure.

Unfortunately, I don’t see either of your two options as feasible for an intramuscular injection scene— either as an anticoagulant or a blood pressure medication. If the character’s blood pressure is too low, the first thing would likely be to give him some IV fluids and just stop the beta blocker.

Some patients do go home on subcutaneous (SQ) anticoagulant therapy, but usually it’s when they have a known clot— not simply to just keep the blood thin. There are too many excellent prescribed oral medications to do this on an outpatient basis. If you wanted your patient to have a clot in the leg (deep vein thrombosis) than this therapy would be reasonable but developing a clot like this would be unlikely if he were already on anticoagulants for his brain coils related to treatment of his first aneurysm. You could read more about this here.

I’m not aware of any blood pressure medicines that are given SQ or IM (into the muscle). There are several given IV in the emergency/ICU setting but these would not be appropriate for home use. Patients are transitioned to home oral medications.

The only medication that could be given consistently SQ on a home basis with any regularity that I could see would be insulin for diabetes.

I did find this pamphlet on-line about SQ meds given in palliative care (hospice) but I don’t think any would fit your scenario. They are mostly anti-anxiety, anti-nausea, or drying agents for secretions given this way because the patient can’t swallow anymore. In fact, most of the links about SQ meds given at home were in conjuction with hospice care.

Also, SQ and IM sites and the angle at which they are given are different as well.

Probably best to find an alternative to this scene.

Medical Review of The Shack

There’s nothing like a Christian movie to create a firestorm of controversy. I am a Christian and saw the film and I thought the biggest failure of the film was actually medical in nature.

That’s right . . . medical.

There have been plenty of articles written on The Shack’s theology, but I doubt anyone has touched on the medical inaccuracies which I’ll do here. If you haven’t seen the movie and don’t want any spoiler alerts then stop reading . . . like right now.

The story revolves around a man named Mack who early in the film narrowly misses a major collision with a semi. At the end of the movie, it’s revealed that he’s been in a coma (he’s been unresponsive) for approximately 2-3 days. Our first glimpses of Mack post accident are in a regular patient room. He has an IV, IV fluids and is on a monitor.

Problem One: If you’re broadsided by a semi, you should actually look injured. Mack is relatively uninjured as a result of this accident. He has but a few scrapes (not even stitches) on his face and none of his bones are broken.

Problem Two: The IV pump is not running. If you watch the film, the IV pump is off. If it were on, you’d see numbers lit up on the screen.

Problem Three: If a patient is unresponsive, you have to provide a way for things to come out. Think about it, do you ever go three days without peeing? Neither does a comatose patient. Plus, we need to ensure kidneys are functioning properly which means we need to monitor urine output. This is the type of patient where the phrase “a tube in every orifice” means exactly what it means. Also, there is a significant amount of literature that patients should be nourished with tube feedings much earlier. In real life, Mack would likely be in the ICU, perhaps even on a ventilator, until he woke up. His only medical support would not just be IV fluids.

Next time Shack, call me.

Medical Errors in Manuscripts: An IV is not a Needle

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)?