Author Question: Unconscious Teen Struck in Head by Baseball Bat

Ari Asks:

Hello and thank you for this blog. It’s a brilliant resource and I’m grateful to have the opportunity to reach out to a professional in this setting.

I have two scenarios in a novel I’m writing that I could use your help with.

First, a teenage boy is struck in the head with a baseball bat. He is knocked unconscious and falls into a coma. When he arrives in the ER, I would like some compelling dialogue between the first responders to convey his condition, rather than just typing it out in the slug lines. What are some of the measures that nurses and/or doctors would take in responding to this injury? Also, what type of jargon or verbiage would make this scene convincing to someone in the field?

Second, is the scenario where the doctor informs the parents of the same boy about his condition. In what setting would he/she do this? Or for that matter, who would be the person to inform the parents to begin with?

Thank you for taking the time to help writers do your profession justice.

Jordyn Says:

Hi, Ari. Thanks for reaching out and all your compliments regarding the blog. I’m glad you’ve found it helpful.

Typically, when a patient arrives to the ER via EMS, they give a report on their patient when they get to the assigned room. In this case, it might be something like this:

“This is John Doe, age 17, struck in the head with a baseball bat at 1600 today. Pt with immediate LOC (loss of consciousness). Was unconscious upon our arrival. Responds only to pain. We started an IV, drew labs, and started normal saline TKO (to keep vein open). His Glasgow Coma Score is eight (this is bad). Vitals signs are as follows: Heart rate 100. BP 124/62. Respirations 16. Pulse ox 100% on 100% non-rebreather. Parents are here. No chronic illnesses. No drug allergies.” 

The ER team will place him on a monitor, assess the status of his IV, and do a thorough physical exam of the patient including an extensive neurological exam. I would follow the link above and do some reading on the Glasgow Coma Scale and how it’s scored.

A Glasgow coma score of eight or less will likely lead to the patient being intubated because there is concern that he would not be able to maintain his airway.

Taking into consideration this patient’s mechanism of injury and the fact that he is unconscious, he would receive an expedited CT scan of his brain to look for injury— likely bleeding in this case.

Past this, it would be hard for me to talk to you about all the things the medical team would say. It’s your scene. If it is a compelling scene in the novel, I’d have a medical person review it.

Keep in mind the POV character you’re writing the scene from. If it comes from a medical person’s perspective, then the use of technical terms, etc is more warranted because they should sound like they know what they’re talking about. If the scene is from a lay person’s POV— then you can write more generally about the medical things being done.

Who informs the parents about their son’s condition? These days, parents are generally not separated from their child, even in instances where the child has lost their heartbeat. The parents likely followed the ambulance and would be updated upon arrival in the patient’s room. A nurse or a doctor can update the parents and give them the medical plan of care as outlined by the physician.

Hope this helps and happy writing!

The Face Behind the Mask: Part 3/5

We’re continuing our five part series with certified nurse anesthetist Kimberly Zweygardt.

Welcome back, Kim.

So far, we’ve met the characters in the OR and discussed the setting. Today, let’s talk about things that could go wrong including anesthesia complications.

We’ve all read about wrong patient or wrong operation or surgeons operating on the opposite leg, hip, etc. Safegaurds, like the time out, are designed to prevent this, but what if it increases plot tension?

Also, the OR is its own little world—only staff and patients allowed, but there was a case where someone impersonated a doctor. What did the nurse say when she found out he wasn’t a real surgeon? “I couldn’t tell. He was wearing a mask!” In a large teaching hospital there are students of all types and the OR gets much more crowded. It would be possible for someone to sneak in with mayhem on their mind, although safegaurds like doors to the dressing rooms with keypad entries have become common.

The OR is a very busy place and patient care comes first. As the case ends and the patient wakes up, there is lots of hub bub.My concern is if my patient is pain free and breathing before taking them to the PACU (Post Anesthesia Care Unit), not about the drugs which locked up unless being used. While I’m gone, the room is “turned over” (cleaned and readied for the next case). Nurses, scrub technicians and housekeeping are in and out. In some OR’s an anesthesia tech cleans and restocks the anesthesia supplies, changing the mask and breathing circuit on the anesthesia machine so that when I return, all I have to do is draw up drugs for the next patient.

Due to the nature of the OR, the anesthesia cart is unlocked so that the tech can restock drugs and supplies. What would happen if someone had murder on their mind?

Drug companies sometimes use the same labels for different drugs. For example, Drug A is in a 2cc vial and slows down the heart. The label is maroon and the vial has a maroon cap. It is clearly labeled as Drug A. Drug B also is a 2 cc vial with a maroon label and has a maroon cap but Drug B increases the blood pressure. What happens if the pharmacist sends the wrong drug because he recognized the colored label and grabbed it? Or if both drugs are in the anesthesia cart, but one vial gets put in the wrong drawer along with vials that look identical? Or the patients blood pressure is dangerously low and in my hurry, I grab the wrong drug and slow down the heart causing the blood pressure to plummet even lower? What if it wasn’t an accident?

For your comfort, practitioners are know about “look alike” drug vials and take special precautions to prevent errors. Don’t be afraid if having surgery, but what fun would that be for our characters? Remember this blog post is about getting the medical details right, not making our characters happy!

***Content originally posted January 28, 2011.***

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Kimberly Zweygardt is a Christ follower, wife, mother, writer, blogger, dramatist, worship leader, Certified Registered Nurse Anesthetist, a fused glass artist and a taker of naps. Her writings have been featured in Rural Roads Magazine, The Rocking Chair Reader, and Chicken Soup for the Soul Healthy Living Series on Heart Disease. She is the author of Stories From the Well and Ashes to Beauty, The Real Cinderella Story and was featured in Stories of Remarkable Women of Faith. She lives in Northwest Kansas with her husband where their nest is empty but their lives are full. For more information: www.kimzweygardt.com

The Face Behind the Mask: Part 2/5

We’re continuing our five part series with certified nurse anesthetist Kimberly Zweygardt.

Welcome back, Kim.

Last post we discussed who is in the OR. Today let’s talk about the OR setting then discuss the anesthetic.

The OR is a cold, sterile, hard surface, brightly lit environment that is all about the task instead of comfort. Cabinets hold supplies, the operating room bed is called a table, Mayo stands hold instruments for immediate use during the operation and stainless steel wheeled tables hold extra instruments and supplies. IV poles,  wheeled chairs/stools and the anesthesia machine and anesthesia cart complete the setting.

When a patient comes in, the staff does a “time out.” The circulating nurse, the surgeon and anesthetist all say aloud that it is the correct patient and procedure. It sounds like this, “This is Mrs. Harriet Smith and she’s having cataract surgery on her left eye.”  Once done, the staff swings into action, the circulator “prepping” the surgical site (washing it off with a solution to kill the germs) while the scrub nurse prepares the instruments after “gowning and gloving” (putting on sterile gown and gloves). Meanwhile, the surgeon “scrubs” meaning washing his hands at the sink outside the room. When he is done, he’ll enter the room to get gowned and gloved. Before all this is happens, I’ve started my care of the patient.

I meet the patient before this to fill out a health history specific to anesthesia. Are they NPO (Have they had anything to eat or drink after midnight)? Do they have allergies? Have they ever had an anesthetic and if so, any complications? Has anyone in their family ever had complications with anesthesia? Then I ask about medications and other health problems  so I can choose the best anesthetic. But an even bigger job is reassuring them that I am there to take care of them.

When they come to the OR, I attach monitors—EKG heart monitor, blood pressure cuff, and pulse oximetry (a small monitor that fits on the finger to measure the oxygen levels in the blood). Once the monitors are on, I give medicines for the  “induction” of anesthesia. As the patient goes to sleep, they are breathing oxygen through a face mask. Drugs include the induction agent (most likely Propofol), narcotics (Fentanyl most common), an amnestic (Versed which provides amnesia), plus a muscle relaxant (Anectine)that paralyzes the musclesWhen asleep, the breathing tube is placed using a laryngoscope that allows me to visualize the vocal chords. Then the anesthetic gas is turned on.

I am with the patient through the whole operation, watching monitors, giving medications and making adjustments.  At the end, I reverse the muscle relaxants, turn off the anesthetic gas, and begin the “emergence” process waking the patient up.

Now, that’s the norm but we’re writers where normal is boring! Next post I’ll let you in on all the things that can go wrong!

***Content originally posted January 21, 2011.***

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Kimberly Zweygardt is a Christ follower, wife, mother, writer, blogger, dramatist, worship leader, Certified Registered Nurse Anesthetist, a fused glass artist and a taker of naps. Her writings have been featured in Rural Roads Magazine, The Rocking Chair Reader, and Chicken Soup for the Soul Healthy Living Series on Heart Disease. She is the author of Stories From the Well and Ashes to Beauty, The Real Cinderella Story and was featured in Stories of Remarkable Women of Faith. She lives in Northwest Kansas with her husband where their nest is empty but their lives are full. For more information: www.kimzweygardt.com

The Face Behind the Mask: Part 1/5

I’m happy to host my good friend, author, and dramatist Kimberly Zweygardt over the next five posts and she shares about being a CRNA— Certified Registered Nurse Anesthetist. You can find out more about Kim by visiting her website here.

Welcome, Kim!

If you have a profession besides writing, doesn’t it bug you when someone doesn’t get it right? It may be something small, but you wonder, “Why didn’t they do some research?”  With the Internet, it is easier than ever to find information, but if it is a hidden profession like my own, there might not be much info for you to glean. Today I want to share with you, The Face Behind the Mask or The Life and Times of a Certified Registered Nurse Anesthetist (CRNA). The operating room is my world, so let’s begin there.

A CRNA is an advanced practice nurse that specializes in anesthesia. CRNA’s were the first anesthesia specialists beginning in the late 1800’s. Anesthesiologists are MDs that specialize in anesthesia (it became a medical specialty after WWII), unless of course you are in great Britain where everyone is an Anaesthetist (Ah-neest’-the-tist’). Confusing, yes? Just remember, the work is the same, but the title is different. For some reason, the term  Anesthesiologist is more widely known (because it is easier to pronounce?), but since CRNAs give over 60% of the anesthesia in the US, if you write a surgery scene, you might want to consider using a CRNA as the caregiver, especially if it is a rural setting. Over 90% of the anesthesia in rural America is provided by a CRNA.

The OR is its own world. Someone has to do the operation, so there are general surgeons, trauma surgeons, orthopedic surgeons (bone), neurosurgeons (brain and nerves), cardiovascular surgeons (heart and major vessels), as well as OB/Gyn (women’s health), ENT (ear, nose and throat) and ophthalmologists (eye surgeon). If it is a large teaching hospital, there might be a medical student or surgery resident assisting the surgeon.

A scrub nurse or surgical technician is there who hands the instruments to the doctor as well as a circulating nurse—a RN who records what happens during the operation as well as obtains any supplies needed in the room. For example, if the doctor needs more suture, the circulating nurse would open it so it remains sterile and hand it to the scrub nurse who is also sterile.

Two of man’s greatest fears are being out of control and the fear of the unknown. The OR setting speaks to both. What great plot scenarios and drama we can create by going through the double doors that lead to surgery!  Next time we’ll talk about interesting scenarios and complications concerning surgery and anesthesia. Happy plotting!

***Content originally posted January 14, 2011.***

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Kimberly Zweygardt is a Christ follower, wife, mother, writer, blogger, dramatist, worship leader, Certified Registered Nurse Anesthetist, a fused glass artist and a taker of naps. Her writings have been featured in Rural Roads Magazine, The Rocking Chair Reader, and Chicken Soup for the Soul Healthy Living Series on Heart Disease. She is the author of Stories From the Well and Ashes to Beauty, The Real Cinderella Story and was featured in Stories of Remarkable Women of Faith. She lives in Northwest Kansas with her husband where their nest is empty but their lives are full. For more information: www.kimzweygardt.com

Author Beware: Don’t Make Medical People Look Like Uncaring Idiots 3/3

Today is the last post on my displeasure with a particular, bestselling novel. Click on the links to find Part 1 and Part 2.

In short, a fourteen-year-old girl has come to Planned Parenthood for the Morning-after Pill.

What follows in italics is an excerpt from the book where the nurse giving the patient her discharge instructions. I’m keeping the identity of the author and the name of the book anonymous.

 girl-1149933_1920Several more minutes ticked by before the nurse, her peppiness especially noticeable in the wake of her cool, serene, superior returned.  A brown paper lunch bag full of brightly colored condoms bunched underneath her arm, a prescription bottle in one hand, and a glass of water in the other.

“Take six right now.” She shook six pills into my clammy palm and watched me chase them down with water. “And six twelve hours from now.” She looked at her watch. “So set your alarm  for four am.” She shook the paper bag at me teasingly. “And being careful can be fun. Some of these even glow in the dark! ”

Wow! Just yikes. Trust me, nurses are usually not so peppy. How does the patient know the “brown paper bag” is full of “brightly colored condoms”? Can she see through brown paper? I digress.

Problem: What’s really wrong with this passage is the patient instructions. The author makes it clear in the novel that the patient is taking the Morning-after pill. There are two such pills. One by the same name and the other is Ella. Neither pill has such a dosing regime. Both are one pill only. That’s it.

I honestly don’t get the point of writing something so ridiculous that is so easily researched.

More seriously, this nurse’s teaching is cringe worthy. I don’t know a nurse on the earth who would talk about condoms glowing in the dark. How about having a serious talk about contraception? How about having a serious talk with a fourteen-year-old girl who is having sex and how she feels about that?

So much more should have been done for this girl in this book by these medical professionals that it was truly disheartening to read. Why? Because this is not the impression I want any woman of any age to expect when they interact with a medical professional about something as important as this.

Writers and authors everywhere— please, do better. Your words educate those we interact with as patients and this is not the impression we want them to have. I’m only asking for one, redeemable, medical person. Make all the rest awful— you have my permission.

Author Beware: Don’t Make Medical People Look Like Uncaring Idiots 2/3

Today, I’m continuing my discussion of an uber popular book that didn’t paint medical people in a good light— like at all.

You can find the first post here. I’m not mentioning the author or the novel here to protect the author from angry medical people everywhere (okay, perhaps it’s just me.)

What follows is the same encounter, different section. As a quick reminder, this fourteen-year-old girl believes she’s been raped and is looking for guidance from a female physician.

What follows in italics is an exert from the book.

doctor-563428_1920-1There had been a question burning in my throat for the last ten minutes, but it was her reaching for the handle of the door that forced me to say it. “Is it rape if you can’t remember what happened?”

 The doctor opened her mouth as if she were about to gasp ‘oh no’. Instead, she said so quietly I almost didn’t hear it, “I’m not qualified to answer that question.” She slipped out of the room soundlessly.

 Problem: There are so many problems with this response from this doctor to her patient that I am flabbergasted as to even know where to start. First, how about starting with a doctor who cares enough to simply ask a few follow-up questions?

Such as, “Please, tell me what happened.”

What is shocking is just the amount of information that has been disseminated to the population about getting mutual consent before a sexual encounter. In fact, in just the last couple of years was the infamous “Tea Consent” video which you can view below.

In fact, the video states, “And if they’re unconscious, then don’t make them tea. Unconscious people don’t want tea and can’t answer the question, ‘Do you want tea?’ because they’re unconscious.” So it seems the issue of whether or not this was consensual would be fairly easy to determine.

No consent, then a crime has occurred.

The first signal to this physician is her patient’s memory problems. This is very concerning for her getting slipped a drug so that she could be raped. If the physician feels this is something she can’t explore, especially considering the patient’s age, then she should seek outside guidance. This could rise to the level of needing to be reported to the police.

Never just stop and not say anything more. This young girl is clearly in crisis. A doctor is qualified to help this patient, particularly one in this setting, who should be clearly educated in circumstances just like this.

Who else can this girl turn to for answers if not a trusted physician?

Author Beware: Don’t Make Medical People Look Like Uncaring Idiots 1/3

I’m starting out my medical posts of the New Year truly fired up . . . and not in a good way. This title sounds harsh, doesn’t it? Sadly, it’s exactly how I feel.

If you’ve known me for any length of time, then you know I’m passionate (just slightly) about medical accuracy in novels. This is why this blog exists and a major reason was to clear up misconceptions about medical people and how they perform in their job.

teen-girl-2Let me first state, clearly, that you can have a bad medical person in a novel. They can even be doing bad things. Criminal things. That’s what drives fiction. Tension. Conflict. However, also should the author help the reader realize, in some fashion, that the author knows this fictional medical character is doing these things inappropriately and it is not a normal medical experience. To help with this, I encourage all authors everywhere to write a medical person performing ethically as a balance in the scene or book. This is beneficial so you don’t anger every medical person out there to want to hold gas and flame to your hard earned written prose.

Professionals like to be portrayed accurately in their profession. Anyone remember how Joy Behar angered thousands of nurses? Yes, this is what writers should avoid.

What follows is an exert from a highly popular mainstream novel. This novel hit both the New York Times AND USA Today Bestseller lists. I’m not naming the book or author here and if you know what either of these are, please do not leave it in the comments section. I’m only using the quotes as a teaching points.

For background, a fourteen-year-old female (from what I can tell from the book) believes she has been raped. She’s going to Planned Parenthood for the Morning-After Pill. The rape occurred on a Friday around midnight. The character is presenting for treatment Monday after school. What follows in italics is an exert from the book.

While she examined me, she explained what the Morning-after pill was. “Not an abortion,” she reminded me twice. “If the sperm has already implanted the egg, it won’t do anything.”

Problem: Medical professionals are careful to separate opinion from medical fact. A patient might view what an abortion is differently than their medical provider and ultimately a medical provider’s job is to disseminate medical information and not their personal opinion. If it is their personal opinion, it should clearly be identified as such.

Some people view abortion as terminating a pregnancy at any stage— including just after fertilization. You will find web sites that claim the Morning-after Pill is not an abortion pill. However, you also can find two, well respected medical sites (Web MD and The Mayo Clinic) that state one of the actions of the Morning-after Pill is “keeping a fertilized egg from implanting.”

Solution:  It would have been better for the medical provider in this passage to simply state the following. “The Morning-after pill works by delaying or preventing ovulation, blocking fertilization, or keeping a fertilized egg from implanting in the uterus. However, there is evidence out there that suggests that it also doesn’t keep a fertilized egg from implanting in the uterus. My personal opinion is that this is not an abortion pill.”

Given this information, a patient can then decide for themselves if this is ethically something they want to choose to do without the personal bias of the medical provider influencing their decision.

A patient should always be given opportunity to choose medically what works within their ethical framework. If the medical provider cannot support them in doing that (what is a reasonable decision) then they should refer them to a provider that can.

Next post, we’ll continue our discussion on the medical issues in this novel.

In full disclosure, I am pro-life.

What are your thoughts on this passage in how the medical provider relays the information to this fourteen-year-old girl?