Wednesday, May 25, 2016

Is a Patient With a Concussion Admitted to the Hospital?


Recently, I finished a book that included the following medical scenario. The main character fell into a river and suffered a broken arm and concussion. During her ER visit, the doctor tells her she needs to be admitted overnight for observation because of the concussion.

This is a common medical myth (along with the one that a CT scan is required in all instances of head injury-- it's not.)

A simple concussion does not need an overnight hospital stay. Let me qualify what I mean by simple. You receive a hit on the head and have one or some of the following global symptoms (dizziness, headache, nausea, vomiting, and amnesia to the events.) Global symptoms mean more than just the bump on your head hurts.

This is really how concussion is diagnosed. CT scan is reserved for concerns of bleeding and/or fracture that might require a neurosurgical intervention. Typically, symptoms associated with bleeding and fracture are persistent and more dramatic. Headache pain is not relieved with medication and/or worsens. There is more than one episode of vomiting. Persistent confusion. Perseverating-- saying the same thing over and over. Inability to move part of the body. Decreased responsiveness. Amnesia that doesn't improve.

A patient with a simple concussion is monitored in the ER for several hours. Typically, we'll give them medication based on their symptoms to see if they improve. For instance, a patient that has nausea, headache and dizziness will get an anti-nausea medication and an over-the-counter pain reliever like Tylenol or Ibuprofen. If their symptoms improve and/or resolve and they can hold something down to eat then they are discharged home with instructions on when to return to the ER.

In order to be admitted into the hospital the patient must exhibit severe, persistent symptomology and/or have bleeding and/or fracture.

In absence of these, the patient will be discharged home.

Wednesday, May 18, 2016

Castle: Dying From Medical Inaccuracy


Personally, I loved the show Castle. Sadly, it's been cancelled and perhaps it's for the best-- especially if Season 8, Episode 21 entitled Hell to Pay is any indication of the attention to detail they were giving their medical/forensic scenarios.

The following is the assessment medical examiner, Lanie Parish, gave concerning New York's latest murder victim.

"He bled to death from a wound in his left side. My guess is whatever he was stabbed with punctured his subclavian artery. After that he would have had about thirty minutes to an hour tops."

There are TWO major problems with the above assessment.

First, your right and left subclavian arteries are located just below your collar bones. So, if you're stabbed in the left side, it's really hard to hit that sucker. That got me thinking about what is on your left side that could cause brisk bleeding. Your spleen is located on your left side tucked pretty nicely under your lower left ribs. Perhaps they meant splenic artery which would have been appropriate for the scenario.

Second is the time frame. If you have a severed artery, the bleeding will be severe and deadly if not controlled in a matter of minutes. There is no way this character would have survived thirty to sixty minutes-- I'd give max time at ten minutes and that might be pretty generous.

So Castle, at least go out on a high note with a medically accurate death scenario.


Wednesday, April 27, 2016

Author Beware: The Right Patient Placement


Coming across inaccurate medical scenarios in books is common for me so to have one raise my ire enough to blog about it generally means a pretty big eye roll was involved when I read the passage.

Scenario: An elderly male dressed in sweats is found wandering the streets of New York in a confused state.

The author's solution: The police take him to a nursing home.

Well, yea, just--- no.

If police find an elderly male, let alone any confused individual, wandering the streets without any ID the first place that person is going is straight to the ER likely via ambulance.

The reason? One, is to make sure nothing medically is wrong. Chronic diseases such as dementia and Alzheimer's are not the only reason the elderly people become confused. Something as simple as an electrolyte imbalance could be the cause. In any new onset confused state, other minor and major medical conditions need to be ruled out first. What might some of those be? Electrolyte imbalance. Brain Tumor. Stroke. Head Injury. Brain Bleed.

Secondly, there is not a nursing home in the United States that will take in an elderly person unknown to them without a medical evaluation first. Plus, do you know all that's involved for nursing home admissions? A lot.

In this instance, if the patient is deemed to not have anything clearly medical (that could be fixed or treated) causing his confusion, then the hospital would involve the police and likely social services for placement.

But no drive by drop-offs at the nursing home.

Wednesday, April 20, 2016

Author Beware: Provider Scope of Practice (EMS)


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.