Wednesday, November 25, 2015

Killing my Arteries: Truth or Die by James Patterson

If you're a frequent reader of the blog, you know I have a love/hate relationship with author James Patterson. LOVE his books but he needs a medical consultant-- STAT.

Recently, I read Truth or Die by James Patterson and Howard Roughan. Here is my Goodreads review of the novel if you're interested.

What I'd like to discuss here is an interesting medical aspect that was part of the book.

SPOILER ALERT. If you haven't read the book and don't want any part of the novel divulged then stop reading right now.

In the novel, a journalist is murdered when she goes to see one of her sources. The question is why? What comes to light is that there has been a new drug invented to be used as a torture device to illicit confessions. In short, the drug will kill you if you don't tell the truth.

The concept itself is intriguing from a fictional point of view and I do give the authors credit for brainstorming this medical scenario and the ethical implications that surround it.

My issue is the way they deliver the drug-- always through an injection into the carotid artery.

I'm sure this is done for dramatic effect but giving drugs via arteries is generally not done. The question is why.

Let's first think of the main difference between veins and arteries. Arteries are vessels that are leaving your heart. The blood has just been oxygenated. These vessels operate under pressure-- we measure your blood pressure at arterial points. Arteries flow into smaller vessel beds.

Veins lead back to your heart. Smaller veins lead to bigger vessels. The oxygen has been off loaded and the red blood cells are on the return trip for more. You have far more veins than arteries.

Many drugs can be "caustic" to veins. This means the drug itself could cause irritation at the least-- loss of the blood vessel at the worst.

Considering how many veins you have-- possibly losing the function of one vein probably won't be a huge deal. However, say I give a drug via your radial artery and completely destroy it. That radial artery feeds a lot of tissue in your hand-- which would die off if the artery were destroyed. That's generally what we consider poor patient care.

The other thing about arteries is that they are usually deeper and harder to access in comparison to veins. As I stated above, they also operate under high pressure. You know you've hit an artery when blood backs up into your syringe-- and pulsates.

Lastly, arteries carry oxygen rich blood to cells. If that blood flow is displaced for a period of time with liquid from an infusion that dilutes the bloodstream-- those tissues could become oxygen starved to the point of dying. Again, generally a bad idea for patient care.

There is an alternative the authors could have used and still had dramatic effect for the book and that would have been IO or intraosseous access. This is where we drill a large needle into your bone marrow. It is considered central access and all drugs could be given this route. Also very dramatic.

Remember, James, I'm available for medical consultation.

Wednesday, November 18, 2015

Murdering a Television Scene

The ABC drama, How to Get Away with Murder, is a series not for the faint of heart. The show centers around defense attorney Annalise Keating (great acting by Viola Davis by the way) and how murder victims keep popping up around her where she may or may not be involved.

The second season opens with an intense scene where Annalise has been shot in the chest and subsequent episodes deal with the events leading up to this one scene. Just who shot her and why did it happen?

Of course, this is a great time to do some medical analysis of her EMS rescue. What's follows is a conversation between two medics who are taking her to the hospital.

Medic One: Starting a 16 Gauge IV. Lungs are clear. Need another blood set for a second IV and a BVM. Blood pressure 70/palp. Pulse is thready.

Medic Two: Feels tachycardic. I'm seeing some JVD. Might have to do a needle thoracostomy. Need to get ETT right away. Diminished respirations. Chest is clear. Equal breath sounds but respiratory effort decreasing.

Just what does all this medical mumbo jumbo mean and is it medically accurate? Well, kind of.

When dealing with a trauma patient, getting IV access is paramount. Usually two lines of a large bore gauge is necessary. A 16 Gauge is a large size. And working to get two lines in is accurate.

What does BP 70/palp mean? Likely, you're used two seeing two numbers in regards to blood pressures. Something like 120/72. The top number is what's referred to as your systolic number-- or the pressure inside your arteries when your heart is contracting. The bottom number, or your diastolic number, is the pressure in your arteries when the heart is relaxing. To get both numbers, you have to be able to listen to the blood pressure by using a BP cuff and stethoscope at an artery point-- usually at the antecubital space (the crook of your arm.) The first time you hear the heart beat-- that's the first number. The moment you can't hear it anymore-- that's the bottom number.

In EMS, active resuscitation scenes are really loud and it's hard to hear. There is  technique where you feel for the blood pressure but you only get one number-- the systolic one. In this technique, you feel where the radial pulse is (at your wrist) and pump the cuff up until you can't feel it anymore. As you let the air out of the BP cuff, you record the number where you first feel the pulse. In this case 70-- which is low. But, that's why there is only one number and the "palp" denotes it was felt or palpated.

Pulse being thready-- means it feels thin and weak. Also appropriate for someone experiencing blood loss related to a gunshot wound. As does what the second medic begins to say-- feels tachycardic which means the patient's heart rate is increasing-- which is also a sign of blood loss.

The main medical inaccuracy with this scene is the procedure one medic says they might need to do-- a needle thoracostomy. Just what is that?

A needle thoracostomy is done to pull air from the chest that has caused a lung to deflate-- here from a gunshot wound to the chest. It is a rescue measure-- meaning it will buy you some time until the patient can get a chest tube placed in a hospital setting.

But note what the medics say over and over-- her breath sounds are equal. These comments denote that her lungs are filling as they should. If one lung was "down" or deflated from the gunshot wound-- the breath sounds should be unequal. Generally, you can't hear breath sounds on the side of the chest where the lung is deflated-- or there is very little air moving on that side.

The writer has also picked the wrong procedure. When one medic comments-- "I'm seeing some JVD."-- this usually denotes an obstruction somewhere in the chest (like a deflated lung or blood collecting around the heart) and blood is having difficulty flowing as it should and so the blood is backing up into the veins. JVD= Jugular Venous Distention and is when the jugular vein is easily seen at the side of your neck because it is filling up with blood.

Since the medics state her breath sounds are "clear and equal" then we know the problem is not with her lungs but could be with her heart.

The rescue procedure for blood collecting around the heart is called "pericardiocentesis".

Again, Hollywood, I am available for medical consultation. Let's rescue our characters using the right procedures.

If you're interested in seeing a video on needle decompression (the first) and/or pericardiocentesis (the second)-- then watch the videos below. They aren't gory.

Wednesday, November 11, 2015

Effects of Electroconvulsive Therapy

Jean asks:

I have a question related to cerebral hypoxia as a complication of old-style electro-convulsive therapy.

I'm plotting out a story that takes place in a psychiatric hospital. My protagonist is a patient at the hospital who was sane and healthy when he was forcibly admitted. He was formerly a thief, and escaped prison by being diagnosed with kleptomania, as a form of monomania. During the year he is incarcerated at the asylum and as a result of the treatments he undergoes, he gradually loses his sanity and his memory.

One of the anachronisms I have in the setting is the existence of electroconvulsive therapy, or ECT, which will be done using the early, more damaging methods. As such there will be no anesthetic, muscle relaxants, bilateral electrode placement or oxygen administered during the procedure. Other than the existence of ECT, the medical knowledge of the doctors at the hospital largely reflects the state of medical knowledge from about 1850 or thereabouts.

I've learned that one of the complications of ECT is the possibility of triggering a prolonged seizure or series of seizures that can last for many minutes during which the patient might be unable to breathe. Currently, doctors can prevent this by administering oxygen and using anticonvulsants to arrest a seizure that continues for too long. Neither of these options is available in a Victorian-based setting in which there were no effective treatments for seizures or coma.

In the plot, the ECT triggers a prolonged seizure and the protagonist is unable to breathe for several minutes. The resulting hypoxia puts him into a shallow coma for a short period of time. After he wakes again, the complications from the hypoxia produce symptoms in him that mimic the psychiatric symptoms that the doctors were expecting to see as a result of his "insanity", such as memory loss, confusion, hallucinations, etc.

The research I've been able to do suggests to me that this is a plausible scenario, but I have no medical training and would greatly appreciate a more experienced opinion. Can hypoxia from a prolonged seizure triggered by old-style ECT send a patient into a coma if given no treatment? How long might be a realistic length of time for the coma to last? How severe could the resulting symptoms be?

Jordyn Says:
Thanks so much for sending me this question Jean and it is an interesting question!
I ran this by a physician friend of mine (thanks Liz!) and here are her thoughts and then I’ll add some of mine.

Liz Says:

I am sure with ECT "anything could be possible" but nowadays it is total disinhibition. These patients become very "frontal"—driven by the frontal lobe and lose their filter, become hypersexual, will say and do anything.

Some can become psychotic which can be accompanied by hallucinations. I don't know if they could have hallucinations WITHOUT psychosis. But I don't think anyone would argue the point since strange things happen in the brain with electricity especially in the setting as the early years of ECT. I’m sure hallucinations could also happen after the hypoxia and coma.

Jordyn Says:

The brain is one organ that we still know very little about. In the presence of hypoxia (or lack of oxygen) the length of coma and the severity of symptoms is largely up to the writer. There is a lot of leeway here. I’ve seen patients wake up from a coma that I would never thought should have survived and I’ve seen patients with more what seemed to be treatable head injuries progress to death.

Hope this helps and best of luck with your book! 

Wednesday, November 4, 2015

The True Side of Sharp Objects

I became a Gillian Flynn fan with Gone Girl. Being a suspense author myself, I like to read what's catching the reader's eye. Particularly a book made into a movie.

After reading Gone Girl, I decided to go back and try one of Ms. Flynn's earlier novels and I chose Sharp Objects. I was interested in this novel because it dealt with the subject of cutting which I've seen more and more in the teenage population and I was hoping the book would offer some insight.

If you haven't read Sharp Objects-- this is your SPOILER ALERT as I will basically be discussing the plot of the novel. You've been warned.

Camille Preaker is a journalist with a history of cutting words into her skin. She was raised in a small town with an overbearing mother and their relationship has been on the rocks since her sibling died many years earlier.

Camille goes back to this small town after a string of grisly murders involving several of the town's children. While living and reconnecting with her mother and getting to know her younger and only remaining sibling better-- she begins to suspect her mother of these murders.

When Camille begins to suspect this, both she and her younger sister begin to get ill and Camille not only suspects her mother of the murders but also of killing her younger sister ala Munchausen's by Proxy.

Munchausen's by Proxy is a mental health disorder where typically an adult caregiver intentionally sickens a child for medical attention.

In order to prove her theory correct, Camille goes to the local hospital to search through her deceased sister's medical records.Which, of course, are released to her without requiring her to sign any sort of medical release. I would question even whether these would be released, at least initially, to a sibling.

While reading the medical record, Camille becomes convinced that she needs to question a particular nurse who brought up concern about this child during one hospital stay.This nurse happens to be on duty on the same unit TWENTY years later. Yea, sure. That's quite a convenient coincidence.

Lastly, the nurse Camille talk to basically says there was nothing she could two decades ago even though she was concerned the mother might be harming the child.

This is patently false. A nurse, even in that time era, was and is a mandatory reporter. A physician's blessing or order is not required to involve social services if the nurse suspects the child is being abused.

I didn't enjoy Sharp Objects nearly as much as Gone Girl and I would suggest reading Gone Girl if you're new to Gillian Flynn. I haven't made up my mind about Dark Places but am willing to give the author another try.

Just wish she would have spoken to a nurse about this scenario.