Surgery

Author Question: The Perfect Skull Fracture

/ Jordyn Redwood / Leave a comment

Ethan Asks:

I’m looking for the Goldilocks of skull fractures. My main character is a college age male that got into a fight. I’ve tried doing my own research but I’m second-guessing myself on which part of the skull to hit. I’m looking for a crack (not a shatter), minimal blood loss, he stays conscious for ten minutes or so, and a hospital stay of about five to seven days. I’m guessing there’s no way to avoid a concussion, as long as there’s no permanent brain damage I can work with it. Is such a skull fracture possible? If so, where on the skull?

Jordyn Says:

Yes, there is such a skull fracture that I think would fit your scenario perfectly.

In a small amount of cases, patients who receive an injury to the side of their head causing a fracture of the temporal bone can tear their middle meningeal artery causing an epidural bleed.

An epidural bleed/hematoma is considered a neurological emergency. Most of these patients will require surgery to save their lives. With epidural hematomas, the patient can have an initial loss of consciousness followed by a distinctive lucid period, and then worsening neurological status after that.

This article gives a nice overview of the condition and treatment for epidural hematomas. Also, this is a good article as well.

Hope this helps and best of luck with your story!

Author Question: Surgery for Shrapnel to the Abdomen

/ Jordyn Redwood / Leave a comment

Naomi Asks:

My protagonist is a surgical resident at large hospital, and I want to write a scene where she is in the OR treating a piece of shrapnel entering the patient’s large intestine with no exit wound.

It took quite a long time to get the patient any sort of medical attention and he has multiple myeloma. I’ve read from my research that myeloma can cause increase inflammation and compression of blood vessels causing coagulation and lessening internal bleeding.

A few questions:

I want to know the chance of my character surviving the surgery. I’m aware since there was no exit wound, and the piece of shrapnel didn’t hit any vital organs, that it would be high chance. However, since he received medical attention rather late (perhaps between half an hour and an hour) I want to know the chance of him actually surviving.

What would be the role of the surgical resident in this scenario? I don’t necessarily just want her to be cleaning up, but I want this to be as accurate as possible.

How long will it take to recover from this surgery?

Are they any complications that could happen during the surgery? If so, please list the major ones.

Jordyn Says:

For this question, I went to one of the best OR types I know . . . my friend Kim Zweygardt who works as a Certified Nurse Anesthetist (CRNA).

Kim Says:

First of all, let’s talk about length of time.

If the shrapnel missed all vital organs and major blood vessels, the length of time to treatment is minor. Are you talking from time of injury? If so, it takes some time for EMS to get to the scene, stabilize the patient, and get to the ER. It takes time in the ER for the nurses to start IVs, for the ER doctor to assess the patient, and get lab and radiology studies to diagnose. It takes time for the surgery to be scheduled and the OR crew to set up for the case.

In a large teaching hospital, is there an OR open or do they have to wait? If the patient isn’t bleeding out, it’s urgent but not life and death. It’s unlikely for the patient to be in the OR from time of injury in half an hour or even an hour.  For instance, in a stat C-section with the patient and crew in house, it’s supposed to be decision to incision within thirty minutes and it’s sometimes difficult to hit that timeline. It takes time to transfer the patient and get the OR ready so I wouldn’t be concerned with that time affecting the outcome in this scenario.

Chances of surviving the operation? It’s kind of a misunderstanding that lots of people die in the OR! Your chances of surviving something is very good in the OR because everything and everybody is there to help you survive— all ways to stop bleeding, medications to resuscitate, etc.

The biggest risk is if the shrapnel was close to major blood vessels that could be nicked by the sharpness during removal.  Most likely scenario is if it’s embedded in the bowel then they would just resect the bowel. In other words, remove the piece of bowel damaged along with the shrapnel. That’s normally done using a special stapler and then reconnected.

It’s possible depending on damage that they’d do a temporary colostomy. Let the bowel heal and go back later to reconnect it.

Biggest worry is infection. Normally when you resect the bowel you do a bowel prep so the colon is empty of stool. The shrapnel itself is dirty but having to resect an unprepped colon— risk of infection is very high and serious enough to cause death. But it’s not an immediate thing. They’d put him on antibiotics but within 24-48 hours he’d have symptoms if infected.

Role of the resident— depends on how advanced they are in their training. If early in residency, assisting. Holding retractors. If more advanced they could do most of the case. In all cases, if an attending surgeon is there, the resident will be left to close the surgical wound, write the orders for post op, and follow up on the patient in the ICU or PACU (Post Anesthesia Care Unit). What they wouldn’t do is clean things up! That is left to the nurses and techs.

His recovery time? If no infection then three to five days if healthy and their bowels are moving to where they can eat, drink, go to the bathroom, etc. With infection recovery time could be weeks or even a month or more.

Hope this helped and best of luck with your story!
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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.

Fox’s The Resident: Everything Stereotypically Bad About Hospitals (Part 1/2)

/ Jordyn Redwood / 2 Comments

Seems like this television season there have been quite a few new medical dramas hitting the airwaves. I’ve done a four part series on The Good Doctor (Part 1, Part 2, Part 3, and Part 4) and 9-1-1. Newest onto the small screen is Fox’s The Resident.

It will make you hate hospitals and everything about them.

There are a few that say to me, “Why try and correct all this misinformation? Most people know it’s not factual.” It might actually surprise you how many people view what they see on television as real and true. The recent demise of crock pots everywhere after an episode This Is Us led the company to release a statement about their safety.

The Resident highlights every horrible hospital stereotype . . . literally on the planet. This is pretty amazing for a show to do in one hour.  The show centers around two residents: the senior resident Dr. Conrad Hawkins and a new bright and shiny resident, Dr. Devon Pravesh. One big problem . . . it’s not even clear what type of residents they are.

Hawkins is the gunslinger. The medical doctor who knows everything under the sun and bucks corruption (and common sense) at every possible turn. He is brash, arrogant, and needs a few classes in mentoring and bedside manner. Well, not just him, but really the entire cast of doctors from the senior attending with tremors who shouldn’t be doing surgery anymore to the wicked smart surgical resident who, in a room full of people (and on the fly by no less) states to a family that the result of their loved ones surgery was “Prescott’s dead.”

Sweet.

I don’t even like this show a little bit. As it stands now, I personally find nothing redeeming about it. Not only medically, but socially as well.

Here is just a short list to get us started on what’s wrong with The Resident.

An open appendectomy. Appendectomies are mostly done laparoscopically. In this patient, it’s even commented that it hasn’t ruptured so it should be the easiest of all appendectomies. However, this patient has a heinously large incision and the attending physician (the one with the horrible hand tremors) nicks an artery and the patient dies.

A short surgical code. It is true that surgeons don’t like deaths to occur in the actual OR. Considering that, the surgical code (compared to a medical code later) is laughingly short. Like big shrugs around the room after a few minutes— golly gee, our patient is dead.  Not sure how we treat hemorrhage.

The cover-up. I can’t say with one-hundred percent certainty that no bad medical outcome is hidden, but I will say that the climate is definitely supporting the truth coming out in the hospital setting. In this television episode, it’s plainly clear that this attending surgeon has a reputation for bad outcomes and the staff has been covering this up for a while. After the patient dies, they develop “the story” to cover up the surgeon’s negligence. Hands down, this puts too many careers at risk and most people aren’t willing to take that chance. This is beyond “playing along”. Most hospitals have corporate compliance hotlines where concerns can be left anonymously. Honestly, it would increase the tension of this television show to have someone trying to expose him.

Next post, we’ll continue our discussion on the medical inaccuracies of The Resident.

 

The Face Behind the Mask: Part 2/5

/ Jordyn Redwood / 2 Comments

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 muscles.  When 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

Author Beware: Taking out Perfectly Good IVs

/ Jordyn Redwood / Leave a comment

If you’re a frequent reader of this blog then you know I have kind of a love/hate relationship with James Patterson. Love his books (most of them), but I frequently take him to task for medial inaccuracies. I rarely call out an author in person or name their book because I like to mostly teach on medical topics, but I think James could use a medical consultant and I also think he has enough money to afford one– though I think these posts are not increasing my chances of working for him.

Anyway . . .

In one of his recent titles, Woman of God, the first part of the book highlights the main character serving as a physician in a war torn region.

Early in the novel, a young boy comes to their primitive hospital suffering from a bullet wound to the chest. During the surgery, which involved opening up the side of his chest, it is noted that the patient stops breathing and so the surgeon, a mentor of the main character, just gives up.

First of all, a patient receiving major surgery like this should be intubated and anesthetized. They do offer surgery, so must provide this to most of their patients. Earlier in the chapter, it is noted that the patient is being bagged and anesthetized patients can’t breathe on their own anyway— so why is a decision made to let him die when he stops breathing when, if properly cared for, he shouldn’t be breathing anyway?

However, this situation does not deter the main character and she continues his operation.

“The heart wasn’t beating, but I wasn’t letting that stop me. I sutured the tear in the lung, opened the pericardium, and began direct cardiac massage. And then, I felt it— the flutter of Nuru’s heart as it started to catch. Oh, God, thank you.

But what can a pump do when there’s no fuel in the tank? 

I had an idea, a desperate one. 

The IV drip was still in Nuru’s arm. I took the needle and inserted it directly into his ventricle. Blood was now filling his empty heart, priming the pump.”

Where to start, where to start.

First, it’s never noted that this patient is receiving blood. I think this is an add on by the author for effect. Secondly, remember IVs are not needles, but very small plastic catheters, that would not be able to puncture through the tough muscle of the heart.

Thirdly, and by far the most egregious, the physician takes out a perfectly good IV for a nonsensical reason! It is hard, really hard, to get IVs into sick kids— particularly those suffering from hemorrhagic shock like this boy is from a gunshot wound to the chest. That one, lonely IV you took out to puncture his heart (not a good idea either), you’re going to need back because this kid will still be sick. You’ll close his chest and then have to find more IV access. Giving fluids via a vein can rapidly fill the heart and it is insanity to take out a good IV to do what the text suggests.

Call me, James. Really. I’m not as expensive as you might think.

Author Beware: This Is Us

/ Jordyn Redwood / Leave a comment

Dear This Is Us— please portray nursing accurately. 

Few can argue with the success of the new NBC drama This Is Us. I’m an avid watcher of the show myself. If you like your heartstrings being tugged at every conceivable corner and you’re not watching then you’re missing out on a great opportunity for a good cry. Well, really, several good cries per episode.

nbc-this-is-us-midseason-aboutimage-1920x1080-koThat being said, I was mildly disappointed in a medical scene portrayed in Season 1, Episode 11. If you haven’t seen it, I don’t think I’ll be spoiling much unless you don’t the the fate of Toby post his Christmas collapse. If that statement is true then you should stop reading here.

In episode 11, Toby is getting prepped for heart surgery. He is anxious, but not overly so. It’s a cute and funny scene. There is a flurry of activity as the nursing staff gets ready to take him to pre-op. The conversation goes something like this:

“Name.”

“Toby Damon.”

“Place of birth.”

“Hope Springs.”

At this point, a nurse comes in with a very large needle and makes it noticeable to the patient.

“What is that?” Toby asks. “Holy Cow. Look at the size of that thing! I’m a big guy but geez.”

The nurse then inserts the needle into the IV port and delivers the medication. Another staff member says, “Look this way, we’re getting ready to take you to prep.”

Toby— after the medication takes effect. “What’s in that?”

Nurse replies, “You’re fine. Don’t worry about it.”

Toby asks again. “What was in that needle?”

Nurse responds. “Just medicine.”

Ugh. I mean, really? Let’s take a look at the medical problems with this scene from mild to annoying.

Problem #1: Place of birth is never asked. Although, I do like that they use what is called two patient identifiers— it’s never place of birth. Usually, it’s your birthday. Also, if he’s going to surgery, there should be some communication with the patient about his understanding of the procedure he’s going to have. “Sir, my name’s Jordyn. I’m one of the OR nurses here to take you to the pre-op area. What procedure are you going to have done today?”

Problem #2: It’s called Pre-op. Not prep.

Problem #3: This is getting more egregious. We don’t insert needles into IVs anymore. They are all needleless system. I get that it looks more dramatic to come in wielding a big needle, but it isn’t medically accurate. I haven’t seen an IV system you had to access with a needle in over fifteen years. In fact, in most tubing systems you can’t even insert a needle anymore.

Problem #4: If you are using a needle and the patient is anxious— don’t show them the needle. Obviously, this is one way to increase the patient’s anxiety which is not the direction we want them to go.

Problem #5: The patient asks the nurse twice what he’s being injected with and she doesn’t disclose it. Honestly, this goes against the very fiber of the nursing code. Nursing is about telling your patient the truth and educating them about what’s happening to them medically. Now, in an anxious patient, the explanation doesn’t need to be long. She could have simply stated, “Sir, it’s very common to be anxious before surgery. This medication is called Versed and will help you relax a little bit.”

Just so the staff writers of This Is Us are aware, I am available for medical consultation. Don’t make me hate a show I love by portraying medical people like they don’t care about a patient’s very direct questions. Little is seen in this scene of the medical staff using other methods to calm and relax this patient other than shoving a medicine in his IV and not even educating him about what it is.

That’s not how we take care of patients.

Author Question: Gunshot Wounds and Rib Fractures

/ Jordyn Redwood / Leave a comment
Shanda Asks:

I have a scene where (in my mind at least) someone very physically fit is shot in the torso as they dive to save another from being shot. They then land excruciatingly hard on the edge of raised concrete (think like the front of an outside step) and break three ribs but that injury goes unnoticed as a result of the gunshot wound.

human-skeleton-163715_1280So my questions are as follows:

1. Would it be possible for someone to pick up the injured and run say a mile or two to get them to where help is waiting?

2. Could it be possible to have surgery for the gunshot would and the rib injuries be missed and hours later cause internal bleeding?

3. What would be the typical recovery time for the first and the latter?

4. Would it be realistic that after the second surgery (for the internal bleeding) the patient could not wake up for days having had two trauma surgeries so close together?

Jordyn Says:

Thanks so much for sending me your questions.

1.  Can someone carry an injured person one to two miles for treatment? It would depend on the physical characteristics of the character who is lifting the other person. Carrying someone one to two miles is a long way. I could possibly imagine a man doing this for an injured female and possibly a very fit male for another male, but a female doing this for a male might be stretching it. It would have to be a very fit female character.

On the other hand, could a character with these injuries get themselves to the hospital? The three cracked ribs are definitely going to slow them down and it also depends on what the gunshot wound has injured which you’re not clear on here. If the gunshot wound deflated a lung then they are going to have a lot of trouble breathing.

2. Could the broken ribs be missed on the first medical exam? Probably no. Any patient with a gunshot wound to the torso is going to get plain x-rays of the chest and probably a CT scan of the chest as well— both of which would show the rib fractures. So in the setting of modern medical care it would almost rise to the level of negligence to miss the rib fractures with a gunshot wound to the torso. I don’t see that happening.

3. To determine your typical recovery time I really need more information on this gunshot wound. Where was the character shot and what was injured specifically? The rib fractures themselves will take 4-6 weeks to heal. Rib fractures are very painful and could inhibit breathing based on their location. Also, successive ribs that are broken in more than one place can create a free floating segment that can be very detrimental to breathing as well.

4. A patient could still develop internal bleeding and need to go back to surgery even if the rib fractures are found right away. This would not be a rare event. It is reasonable for a patient to not wake up for a couple of days if they suffered a code during the second surgery due to extreme blood loss and had flat lined for a period of time.

Even the stress/shock of the surgeries close together might be enough for the brain to check out for a time. The problem with a comatose patient is they have to be in the ICU, on a vent, with a tube in every orifice as they say. For instance, a patient can’t be out cold and have no way to pee— so a catheter has to be placed so the urine can come out.

Going down that road can get very complicated for a novel depending on whose POV you’re telling it from.

Best of luck with your novel!