Wednesday, July 29, 2015

Ahhh-- James Patterson and Medical Fictionism

First, let me be clear. I am a fan of James Patterson. I love his novels-- mostly I'm sticking to the Alex Cross novels these days.

However, I also have a love/hate relationship with Mr. Patterson. LOVE the Alex Cross novels-- hate the medical info.

I don't think Mr. Patterson is hurting for money which is why I've requested several times on this blog for him to hire me as his medical consultant-- because though he's a great story teller-- he does need help in this area. 

In Hope to Die (Alex Cross #22) James sets up a very implausible medical scenario that I'm going to discuss here. There are spoilers in this post-- you have been duly warned to read no further if you haven't read the novel. 

In this book, Alex's entire family is kidnapped. That includes his ailing, elderly grandmother (who is at least in her late 80s or early 90s from what I can tell), his middle-aged wife and a couple of teen-aged kids.

They are drugged, placed on life support and housed in a cargo container for about a week, On top of that, the cargo container is being moved (placed on a boat, etc) so it is not stationary.

AND-- there is not a medical attendant 24/7. Just a group of people, drugged, on life support for a week. Oh, they are checked ONE time during the week.

Okay-- sure.

Let's talk about the medical aspects and how this scenario would never work.

1. The tubes. When someone is on life support-- there's going to be a tube in every orifice as they say. The tube that keeps them breathing. A tube into their stomach to drain secretions. A tube into their bladder to drain their urine. And they will still poop-- I'm just being real people. So if no one is there to drain these items and ensure that they stay in the proper place it will cause life threatening issues for the patient.

2. The drugs/fluids. It's not so much that I have a problem with the drugs that were used-- more the fact that no one is there to change them out. Keep in mind, someone on life support cannot eat or drink for themselves. This has to be provided for them. If your goal is to just keep them hydrated then an adult needs, let's just say, 100ml/hr to maintain hydration. That means a one liter bag is going to last 10 hours. Then the sedation drugs themselves need to be changed out as well-- they are not going to last forever.

3. The oxygen. It is very rare that a ventilator doesn't use oxygen. Ventilators generally don't run off O2 tanks. They need a special source with adapter. So, how are all four of these vents running? Even if we could leap to oxygen tanks-- again-- who is changing them?

4. Electricity. Everything connected to the patient runs on electricity. IV pumps can run on batteries for a certain length of time but probably not more than 12 hours. Ventilators require a power source-- they must be plugged into something. There is nothing scarier for an ICU nurse than when the electricity goes out and you're waiting for a back-up generator to kick in. Most often-- this is seemless because vents are plugged into emergency outlets that are always fed electricity expcept under dire circumstances-- like a hurricane or tornado takes out your back-up systems. If that happens, the patient must be manually bagged with an oxygen tank.

5. Turning. If bed-ridden patients aren't repositioned every few hours they are going to develop pressure sores. This puts the patients at risk for skin breakdown and infection. Also, immobility increases the risk of developing blood clots as well.

6. Drug Metabolism. The author is also assuming patients metabolize drugs and use the same drug dose. This is not true. Drug dosages in pediatrics is calculated based on the patient's weight. Adjustments are made in the elderly population as well.

So James-- loved the story but the medical scenario . . . please.   

Wednesday, July 22, 2015

The Problem with Camels and MERS


If you're like me then you're intrigued by viruses and how viruses are transmitted-- then you'll be fascinated by the story of MERS (Middle East Respiratory Syndrome.)

MERS is a coronavirus (in the same family as SARS-- Severe Acute Respiratory Syndrome). It first popped up in Saudi Arabia in 2012.

On June 9th, 2015 the World Health Organization issued a statement encouraging people not to eat or drink uncooked or unpasteurized camel products-- including camel urine. Of course, that was the big headline.

What's interesting is that if you read further into this statement, it's not exactly clear how MERS began to infect humans. We know that humans can infect one another but not easily which is good news.

How did humans first become infected? What is the reservoir-- that seemingly innocuous place where the virus lives but doesn't necessarily make its host sick?

Strains of MERS that have infected humans have also been found in camels. It is possible that other sources exist in animals but none have been identified yet. The WHO believes this then supports the theory that human infection is coming from camels.

It doesn't take much of an internet search to determine that consuming camel products may be culturally important in the Middle East-- hence the warning.

If you'd like to read more about MERS and its animal to human transmission then check out this link.

Wednesday, July 15, 2015

Author Question: Survival After Abdominal Aorta Injury


Jessica Asks:

I'm writing a war scene where a character is hit by a piece of shrapnel in the abdominal aorta; the other things I wanted to know were:

1. How long would he remain functional (as in able to walk, run, shoot etc) with that kind of blood loss?

2. This character wears a device called a 'Scorpion' which is an injector that dumps stimulant drugs into his bloodstream. Would this cause him to bleed out faster? 

Jordyn Says:

The abdominal aorta is a large blood vessel in your abdomen. The answer to your questions depends on how badly the abdominal aorta is injured. If it was simply nicked—that would give your character some more time and if his limbs were uninjured he could probably run, walk, and shoot if the injury to his belly wasn't grievous. Theoretically, if it was just a little leaky he could do all right but I'd make it clear to the reader that the medical team found that the abdominal aorta wasn't really injured.

If his abdominal aorta is completely severed-- he's dead in under one- two minutes. That's a fatal wound. The odds would be against him even if he were inside a hospital when this happened. He might be able to hold a weapon and fire for a few seconds but I don't see him being able to stand, etc.

As far as would the use of a stimulant cause him to bleed out faster--- yes, if nothing is stopping the flow of blood like a dressing. A stimulant increases your heart rate so it's like turning a hose up with a higher flow-- if nothing is capping off the end of the hose the fluid loss would be greater.


Hope this answers your questions and happy writing!


Wednesday, July 8, 2015

Pediatric Psychiatric Issues: The M-1 Hold


As many readers of this blog know, I'm a pediatric ER nurse. What that means is that I just don't take care of newborns and toddlers but also teens and young adults up to the age of twenty-one.

Particularly, in the last five years or so, I've helped care for an increasing number of patients that have been placed on M-1 holds. An M-1 hold (it may go by other names in your area) is essentially a mental health hold or involuntary placement into the hospital for a mental health evaluation.

In our hospital system, there's not a required length of stay but it does mean that, essentially, we take over custody of your child until this evaluation takes place. That means that you as the parent cannot take your kid from our facility and we can transfer them where they need to go without your consent.

Your child can be placed on an M-1 hold by two parties-- either law enforcement or a physician. Sometimes kids come in via police already on an M-1 hold.

A patient is usually placed on a hold for expressing thoughts of wanting to hurt themselves or others by making these statements to either a parent, school counselor, mental health counselor, physician or law enforcement officer.

When a patient makes these statements or requires medical treatment for self-harming (cutting too deep that the cut requires sutures) or outright suicide attempt (like drug overdoses) then they're placed on an M-1 Hold. Emergent or stabilizing medical treatment is always handled first.

When a patient is placed on an M-1 hold, the medical staff must provide for the patient's safety.

We have them change into scrubs of a particular color and confiscate all their clothes. This means everything but their underwear (excluding bras-- yes, they must remove those as well) and perhaps socks. Part of the reason for this is to keep them from fleeing (by taking their shoes) and also as a security measure so staff know that a person leaving the facility in those scrubs needs to be stopped. They also cannot wear hair bands, necklaces, or bracelets. All piercings need to be removed.

They are placed in a "safe room" which, at our hospital, is not the "rubber room" you might imagine but it is devoid of basically everything but the bed and a chair. No cords. No monitor. No alcohol hand gel.

The patient is asked to provide a urine sample. Girls are tested for pregnancy above the age of twelve. All are tested for drugs. If they give a concerning history for possible ingestion-- blood tests may be added to test for aspirin and acetaminophen which can be deadly overdoses.

The patient is then scanned for metal using a wand-type device that you see at airports.

At all times, the patient is under one-on-one observation by someone on our staff even if they have a parent present.

After that, the physician will have a talk with the patient alone, the parents alone and then both parties together if the patient agrees. After that, the physician touches base with the mental health staff to determine the best course of action for the patient.

With the advent of telehealth, some of these mental health evaluations can take place with face-to-face interaction over the computer. This has helped decrease the need for transfers but is a very lengthy process. Each interview mentioned above also takes place by the mental health counselor. Each interview can take 30-60 minutes.

If a patient is transferred, it must be by ambulance. Parents are not allowed to ride in the ambulance for this type of transfer. Again, this is a safety measure. It may be surprising but sometimes parents can complicate matters and for the safety of the EMS team-- they take only the patient.

I hope this provides insight into what will happen if your child is placed on an M-1 hold or you need it for a scene in your novel.