Happy New Year's... Eve that is.

New Years Resolutions: are they fun for you? Challenging? How long do yours last? What are some goals you have for the coming year?

Me? Write novel #2 in my medical suspense series. Novel #1 is in the hands of my trusty agent and hopefully will find a publisher this year. If your a novelist, how long does it take you to write a book? I'm hoping to beat my last average, which all together was five years. Though, if my agent reads this and is having a coronary as we speak, I did write 75% in one year... so rest easy. I'm hoping to shave a good four years off my previous timeline.

What about you?

Music Box Dancer

Last one of my favorite holiday house. How did you celebrate the holidays?

Jordyn

Silent Monks Singing Halleluia

More holiday fun! Hope you're having a great time celebrating.

Jordyn

Christmas Light Show - Amazing Grace

We're taking a light hearted approach over the next several posts. I'm a Christmas fiend at heart. I love the lights, the singing, and the gift giving. We'll resume our usual medical mayhem January 3rd. If you wander by Redwood's Medical Edge over the next week or so... enjoy the holiday fare.

Merry Christmas!

Jordyn

Preventing Holiday Injuries

I often get asked, "Are there any injuries specific to certain times of the year?" There are seasons for certain ailments and injures. For instance, kids drown more commonly during the spring/summer (except bathtub drownings are year round). I've only seen fishhooks embedded in not so fun places during the summer. Now, if I were a nurse where ice fishing were popular, then this may be a more year round occurrence. Unfortunately, there seems to be at least one story every year of a house burning down from a Christmas tree fire.

Specific to pediatrics (and adults in some cases), there are illnesses that are seasonal. Flu (the respiratory kind) is prevalent in late fall and winter. The respiratory syncytial virus (RSV) affects infants and children during this time as well. Rotavirus also comes out to play during this time of year. Considering all these illnesses, it's not hard to understand why patient volumes and wait times increase during the winter.

So... stay safe out there and check out this article on holiday safety: http://www.medicinenet.com/script/main/art.asp?articlekey=15239

Hope everyone has an amazing Christmas!

Jordyn

Winner: Pat Davis!

Pat Davis is the lucky winner of a signed copy of Sarah Sundin's novel A Distant Melody. Congratulations Pat and thank you to all who left comments this week. A big thank you to Sarah for her amazing posts and offering up our prize.

Medical Scene Diagnosis: Christine Lindsay

Christine Lindsay submitted this short medical scene for review. Check out some of the finer points that a medical review can add to your novel. Also, I'd like to wish Christine a very happy birthday today!! She has many exciting things going on as she just received a contract on her novel Shadowed in Silk. Congratulations.

This scene comes from her next novel, Sofi's Bridge:

Neil pulled back the man's eyelids. The pupils dilated equally. He ripped open the blood soaked trouser leg, trying in vain to wipe away the seepage. It was as he feared, a bullet wound. 

           Neil picked up the man to take him to the shack. The dog bounded beside him. Sofi ran before Neil as he staggered with the weight he carried.

            “Clear the table,” he ordered.

            She helped him lay the patient on the table covered by an oil skin cloth.

            Outside, on the track the locomotive slid past. Red, white and blue rosettes, and bunting beribboned the front of the cow catcher. Steam rose from under flanged wheels as the locomotive ground to a stop outside the shack.

            On the opposite side of the table, with the patient between them, Sofi drooped her head.

            Neil bent over to examine the wound. He released a sigh of relief that jarred with frustration. The bullet had missed the femoral artery and was lodged in fatty muscle. The patient would be alright. His skin was dry and warm. Though he gritted his teeth in pain his pulse was strong and steady. With the pupils dilating normally, and the chest rising and falling evenly at a normal rate, this man did not need immediate surgery. Neil could have very well left him in Sofi’s hands as she’d begged him, and been deep in the forest by now.

My first comment is about pupils A normal pupillary response to light is to constrict, not dilate. You can check this out for yourself on a friend with a low powered flashlight. Shine the light at their eyes and you should see the black part constrict. Both pupils should constrict together, equally, even when the light is aimed at only one eye.

My second thought is the description of the bleeding. For a bullet essentially lodged in fat tissue, the bleeding sounds more severe than what I would expect. Though, venous bleeding can be fairly significant as well. You can die just from venous bleeding. Overall, I think as a writer you would have some latitude here. I've included some other descriptions that are highlighted that could clarify the patient is not in shock.

Any other thoughts for Christine? 

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Christine Lindsay is a writer of historical romance. In the case of her debut novel SHADOWED IN SILK which will be released in summer 2011 by WhiteFire Publishing, Christine's writing leans more to a historical novel with a strong love story. SHADOWED IN SILK won the 2009 ACFW Genesis award for Historical under the previous title UNVEILED. Christine is currently at work on SOFI'S BRIDGE which won 2nd place in the 2010 RWA Touched by Love contest and which is clearly a Historical Romance. Christine's true-to-life experience as a birthmother--a woman who relinquished a child to adoption--is found in the Focus on the Family book, Thriving as an Adoptive Family. The entire story of her relinquishment and reunion with her birthdaughter 20 years later can be found in book form on her blog. Christine lives in British Columbia, Canada with her husband and grownup family close by. Her cat, Scottie, is her chief editor as he's always at her side. Find out more about Christine’s forthcoming novel at: www.christinelindsay.com/2010/11/unveiled-long-awaited-announcement.html.

Sarah Sundin: WWII US Army Hospitals

This is Sarah's final installment on Army Hospitals. I'd like to thank Sarah for all her hard work on these terrific posts. Be sure to leave a comment this week for your chance to win a personalized autographed copy of your choice between A Distant Melody or A Memory Between Us. 

US Army Hospitals in World War II—Part 3

Ruth squatted beside his cot. “Have you ever flown before, Corporal?”

            “No, ma’am. A man’s meant to stay on the ground.”

            “How long did it take you to get to England?”

            “Almost two months, ma’am, zigzagging around them U-boats.”

            “Mm-hmm. Well, tonight you’ll have dinner in New York. You may change your mind about flying.”

In my novel A Memory Between Us, the heroine becomes a flight nurse, pioneering medical air evacuation. If you’re writing a novel set during World War II, a soldier character may get sick or wounded, and you’ll need to understand how patients were evacuated from the battleground to the hospital and perhaps taken stateside.

On December 13^th,  I discussed the chain of evacuation, on December 15^th, I discussed more details about mobile and fixed hospitals, and today I’ll cover evacuation of the wounded.

Manual Transport

On the battleground, medics or fellow soldiers could manually carry a wounded man further to the rear for aid. Methods included the supporting carry (walking side-by-side), the arms carry, the saddleback carry (piggy-back), and the fireman’s carry.

Litter Transport

American litters were made of canvas stretched over aluminum or wood poles with stirrup-shaped feet to keep them off the ground. A litter could be carried by two people, but a litter squad consisted of four men, to rotate if traveling long distances and to assist over obstacles. Ideally, litter transport was only used for short distances, but in mountainous or forested or swampy terrain, litter transport was the only available means. Mules were often used in the Mediterranean Theater to carry litters in rocky, mountainous terrain.

Motor Transport

Ambulances were used to transport patients, usually from an aid, clearing, or collecting station to a field hospital, or for transport further to the rear. Ambulances could carry seven seated patients or four patients on litters.

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Jeeps were often used, both on the battleground and to transport further to the rear. Rugged and maneuverable, jeeps could cover terrain inhospitable to ambulances. With litter brackets, a jeep could carry two patients. Armored divisions also used light tanks to transport their wounded.

Water Transport

During an amphibious landing, the best way to handle the wounded was to send them back on departing landing craft, which carried them to hospital ships off-shore. Patients could be removed from danger and transported quickly to get needed care.

Hospital ships were used offshore after an invasion to care for the wounded before field and evacuation hospitals could be set up. They also transported patients who needed long-term care to general hospitals further to the rear. Another use of hospital ships was to transport to the US any patients who needed long-term convalescent care or those who qualified for a medical discharge. They carried several hundred patients and delivered full medical care, but transport took a long time and carried the danger of enemy attack at sea.

Rail Transport

Hospital trains were used within theaters of operation to transport patients from one hospital to another. They were used in the continental US, Britain, continental Europe, India, and North Africa. They could carry several hundred patients with excellent medical care.

Air Transport

Medical air evacuation was new and revolutionary, but by the end of the war, it proved successful. Planes can traverse inhospitable terrain or dangerous seas—and quickly. At the front, the wounded were gathered at collecting stations at airfields. C-47 cargo planes carried 18-24 litter patients or a higher number of ambulatory patients further to the rear. A team consisting of a flight nurse and a surgical technician cared for the patients in flight. The larger C-54 cargo plane was used for trans-oceanic evacuation. Danger still existed, both from the inherent risks of flight and also because the planes carried cargo and couldn’t be marked with the Red Cross.

Resources for Research

Office of the Surgeon General. Medical Field Manual: Transportation of the Sick and Wounded. Washington, DC: US Government Printing Office, Feb. 21, 1941 (available free on-line at http://www.ibiblio.org/hyperwar/USA/ref/FM/index.html ). Please note the date—some of the material, especially about air evacuation, became quickly outdated.

For better information on air evacuation, please see:

Links, Mae Mills & Coleman, Hubert A. Medical Support of the Army Air Forces in World War II. Washington, D.C.: Office of the Surgeon General, USAF, 1955.

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Sarah Sundin is the author of the Wings of Glory series from Revell: A Distant Melody (March 2010), A Memory Between Us (September 2010), and Blue Skies Tomorrow (August 2011). She has a doctorate in pharmacy from UC San Francisco and works on-call as a hospital pharmacist

Sarah Sundin: WWII US Army Hospitals

Remember, if you leave a comment this week on any of Sarah's posts, you'll be entered into a drawing for a personalized autographed copy of your choice between A Distant Melody or A Memory Between Us.

US Army Hospitals in World War II—Part 2

Ruth passed precise military rows of the hospital’s Nissen huts. Redgrave Hall stood to the west, but she headed south across the road the ambulances used and entered a lightly wooded meadow and another world. How could one family own so much land?

            If Ruth had resources like that, she wouldn’t be in a fix.

In my novel A Memory Between Us, the heroine serves as a US Army nurse based in England. If you’re writing a novel set during World War II, you may need to write a scene set in a military hospital, and you’ll need to understand Army hospitals.

On December 13^th, I discussed the chain of evacuation, today I’ll discuss more details about mobile and fixed hospitals, and on December 17^th, I’ll cover evacuation of the wounded.

Mobile Hospitals

Field hospitals (400 beds) and evacuation hospitals (either 400 bed or 750 bed) arrived within a few days of an invasion and followed the army, staying about thirty miles behind the front. They were close enough to treat patients quickly and send them back to the front quickly as well.

These hospitals relied on mobility. They usually used canvas tents, but also used schools, barracks, hospital buildings, hotels, Mediterranean villas, and an Italian stadium. A few days before a move, the hospital stopped admitting patients and evacuated their current patients to other hospitals. They packed their equipment and personnel into trucks, advanced, set up, and were ready to admit patients within hours.

When ambulances arrived, triage officers sent patients to pre-op, medical, shock, or evacuation wards as needed. Surgical teams worked twelve hours on, then twelve hours off.

In the European Theater (England, France, Belgium, Germany), the field hospitals stayed closer to the front, with the evacuation hospitals further to the rear. In the Mediterranean Theater (North Africa, Sicily, Italy, southern France), field hospitals and evacuation hospitals were often used interchangeably. Both theaters practiced “leapfrogging” as the front advanced—hospital A would pass hospital B, then hospital B would pass hospital A. This reduced the frequency of moves.

Fixed Hospitals

The station hospitals (250, 500, or 750 bed), general hospitals (1000 bed), and convalescent hospitals (2000 or 3000 bed) were set up far from the front to keep patients safe from danger, but also to keep them in the theater, which made it easier to return the soldiers to duty. In England before D-Day, field and evacuation hospitals waiting for the Normandy invasion functioned as station hospitals to care for patients.

In each theater of operations, fixed hospitals operated in what was called the “Communications Zone.” In the European Theater, the COMZ was originally in England, then as the Allies approached the German border, the COMZ extended to include Normandy and Belgium. In the Mediterranean Theater, Morocco served as the first COMZ, then Algeria. When the Allies invaded Sicily and Italy, North Africa was the COMZ, and as the front advanced, the COMZ was established in the Naples area of southern Italy. In the Pacific, fixed hospitals were first established in Hawaii and Australia, then followed into secured regions.

Fixed hospitals moved less often and occupied more permanent facilities. American units used some standing hospitals in host or occupied countries, but most were a collection of Nissen huts, 20-ft by 40-ft corrugated tin semi-cylinders. In England, these hospital complexes were often placed on estate grounds, and had concrete floors, flush toilets, clean water, and were heated by coal-burning stoves. In the Mediterranean and Pacific, facilities were more primitive but improved over time. In these theaters, mosquito netting was draped over the beds to prevent transmission of malaria.

Fixed hospitals in the Zone of the Interior (continental United States) enjoyed the benefits of modern buildings and facilities. However, shortages of medication, equipment, and personnel were always a problem.

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Sarah Sundin is the author of the Wings of Glory series from Revell: A Distant Melody (March 2010), A Memory Between Us (September 2010), and Blue Skies Tomorrow (August 2011). She has a doctorate in pharmacy from UC San Francisco and works on-call as a hospital pharmacist

Sarah Sundin: WWII US Army Hospitals

I'm so thrilled to have Sarah back this week. If you're looking for information surrounding WWII, check out all of her posts. Last month she did a series on WWII nursing. They're an excellent resource. If you leave a comment this week on any of Sarah's posts, you'll be entered into a drawing for a personalized autographed copy of your choice between A Distant Melody or A Memory Between Us.

US Army Hospitals in World War II—Part 1

Lieutenant Doherty wrote on the clipboard while the mercury rose, and Jack glanced around the Nissen hut, which was like a giant tin can sawed in half. Four coal stoves ran down the aisle, with ten beds on each side, only eight of which were occupied. Jack didn’t mind the extra attention.

In the Wings of Glory series, my B-17 pilot heroes keep getting injured and hospitalized. If you’re writing a novel set during World War II, your soldier characters may need treatment, and you’ll need to understand how and where patients were hospitalized.

Today I’ll discuss the chain of evacuation, on December 15^th, I’ll discuss more details about mobile and fixed hospitals, and on December 17^th, I’ll cover evacuation of the wounded.

The Chain of Evacuation

Wartime medical treatment occurred on muddy battlefields under fire, tent hospitals only miles from the front, and sterile stateside hospitals.

A complex chain moved patients to where they could best be treated. At all points along this chain, decisions were made regarding when to treat, when to return to duty, and when to evacuate further to the rear.

Organic Medical Units

These units were attached to combat units and followed them into battle.

Battlefield: Medics performed first aid and moved the wounded to the aid station, often under fire.

Battalion aid station: About one mile from front. Physicians and medics adjusted splints and dressings, administered plasma and morphine. Soldiers reported to the aid station for treatment of minor illnesses or mild combat fatigue.

Collecting station: About two miles from front, near regiment command post. Further adjustment of splints and dressings, administration of plasma, treatment of shock.

Clearing station: About four to ten miles from front. Treated shock and minor wounds. Grouped patients in ambulance loads for transport to field hospitals.

Mobile Hospitals

These hospitals were assigned to a theater of operations, and could be packed and moved quickly.

Field Hospitals: Within thirty miles of clearing station—were supposed to receive the wounded within one hour of injury. Surgery was performed for the most severe cases.

Evacuation Hospitals: Treated illnesses and less urgent surgical cases. Patients could be reconditioned here to return to the front.

Fixed Hospitals

These hospitals were set up a safe distance from the front, either in the theater of operations or stateside.

Station Hospitals: Usually attached to a military base, designed to treat illnesses and injuries among personnel stationed at that base.

General Hospitals: Large facilities where patients received long-term treatment.

Convalescent Hospitals: Designed for rehabilitation.

Resources for Research

Cosmas, Graham A. & Cowdrey, Albert E. The Medical Department: Medical Service in the European Theater of Operations. Washington, D.C.: United States Army Center of Medical History, 1992.

Wiltse, Charles M. The Medical Department: Medical Services in the Mediterranean and Minor Theaters. Washington, DC: Office of the Chief of Military History, Department of the Army, 1965. (available free on line at http://history.amedd.army.mil/books.html)

Condon-Rall, MaryEllen & Cowdrey, Albert E. The Medical Department: Medical Service in the War Against Japan. Washington, D.C.: United States Army Center of Medical History, 1998.

Links, Mae Mills & Coleman, Hubert A. Medical Support of the Army Air Forces in World War II. Washington, D.C.: Office of the Surgeon General, USAF, 1955.

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Sarah Sundin is the author of the Wings of Glory series from Revell: A Distant Melody (March 2010), A Memory Between Us (September 2010), and Blue Skies Tomorrow (August 2011). She has a doctorate in pharmacy from UC San Francisco and works on-call as a hospital pharmacist

Medical Question: Burns

Jennie Atkins poses this question:

What happens when someone gets burned - what do the EMT's do on the scene? The story line involves the explosion of a crosswired electrical box.  Two individuals are burned.  First, the man who threw the switch is thrown onto the floor and sparks are showering down on him and his clothes.  He is pinned beneath a shelf that he knocked over.  The second man takes his jacket and tries to put out the flames while others pull the shelf off the man on the floor.    The second man's arm and hand are burned trying to put out the fire, and keep the sparks from falling on the man on the floor. 

I have the paramedics taking the first man to the hospital - I describe very little about his condition.  However, the hero is attended by the heroine who is an EMT.  His burns are secondary. Would he have to go to the hospital?  Get a tetanus shot - if he needs one?

Answer:

The first distinction to make is that there are several different types of Emergency Medical Service (EMS) providers and their level of responsibility to this patient will be different. An emergency medical technician (EMT) generally provides basic first aid, CPR, can administer oxygen and can assist the patient in giving their own medications (like an asthma inhaler or nitroglycerin tablets). A paramedic does more advanced medical procedures and gives drugs. The level of your provider will need to be clear in the medical care they can provide.

For EMT's, in general, burn care is as follows:

1. Remove clothing from the burn that is non-adherent.
2. Remove any constricting items. For instance, if the burn is on the ring finger, you would try and take the ring off.
3. Cover burn with a cool, wet, clean dressing. This will help control pain.

If you have a paramedic responding-- it is possible that an IV could be started and the patient could get IV morphine for pain.

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If the character is burned by the electrical current, this poses a whole new set of problems. I get the feeling he is burned by the electricity because you mention that he has been thrown back. Electrical burns typically have an entrance and an exit wound... say the hand and the foot. The electricity enters one part but has to exit somewhere. The other problem with electrical burns is that your heart pumps based on an electrical conduction system. An electrical burn can injure the electrical conduction system of the heart and we will look very closely at whether or not the heart sustained injury. The issue with electrical burns is that the damage is often unseen because the electricity will injure you internally but we can't see it externally except and the entrance and exit sites.

The other thought was the extent of your patient's burns and this would make a difference in their medical care. Burns <15% body surface area (BSA) would get cool, moist compresses. However, burns > 15% would get dry, sterile dressings. The reason for this is that burn patients have lost their skin integrity. Your skin helps your body maintain its temperature. Some consider it the largest organ in the body. When you burn >15% and apply cool, wet dressings, this can pull enough heat away from the patient to cause them to become hypothermic. We actually have to help them maintain their body temperature by cranking up the heat in the room or using other warming techniques.

Your patient will have to go to the hospital. Initial ED treatment would be IV placement, fluid resuscitation (there is a formula we use for this-- depends on the burn percentage), pain medication (like morphine) and likely consulting with a burn center to help determine his course of treatment. Tetanus shot would be updated if he hasn't had one in the last five years.

Did you know that paramedic protocols are relatively easy to find online? Here's one that I like: http://web.me.com/dmemsmd/DMEMSMD/Welcome.html. Also, here is a link if you need a diagram to help you estimate how large your character's burn is: http://www.primary-surgery.org/ps/vol2/html/sect0105.html. You can find additional references by typing in at Google University: "paramedic protocols" and "burn charts".

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Jennie Atkins, a Software Engineer by trade a writer by desire, lives in the small rural community in eastern Ohio along with two spoiled yellow labs. An avid gardener, she also loves to make quilts and sings at her local church.  Jennie has a B.S. in Information Technology Management from Kaplan University and is an editor for MBT Ezine Magazine’s Let’s Shout It Out column. Along with her Ponderer’s Blog entries at http://mbtponderers.blogspot.com/ you can visit Jennie at her website http://www.jennieatkins.com/.

Medical Question: Brain Infections

We're finishing up with Dale's questions. He asks: I have a character who is overcome by huge amounts of stress, and ends up in a coma for three days. The character suffers from Viral Encephalitis which is brought on from huge amounts of stress, and I only have a little bit of info about this. I got the idea from a real life FBI profiler who went through this. But he only went into a few paragraphs of what it was like. So I was wondering if you had any info about how someone would be cared for in this condition from the time of admittance, to the time of release?

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To start, let's deal with what is viral encephalitis. Encephalitis is inflammation of the brain and/or spinal cord. Viral encephalitis means the inflammation is caused by a virus. When this type of patient presents to the ER, it may be hard to differentiate between encephalitis and meningitis. The meninges are composed of three membranes that cover your brain and spinal cord. The three membranes are: the pia mater, arachnoid mater, and dura mater. Symptoms of both encephalitis and meningitis can be fever, photophobia (sensitivity to light), headache, stiff neck, pain upon moving the neck, nausea and vomiting, and seizures. There are other symptoms as well. This is the short list.

One thing that struck me about Dale's question is the stress aspect and why it made this FBI agent vulnerable. Stress weakens your immune system but wouldn't be the cause of the encephalitis. There needs to be a causative agent (like a virus or bacteria) but he was likely set up to be more vulnerable by the stress he was under.

In the ER we'll draw blood to look at what the patient's white count and inflammatory makers are. He may get a CT or MRI of the head. We absolutely will have to get a sample of spinal fluid through a lumbar puncture. Typically we have to collect a culture sample of the cerebrospinal fluid before we give any antibiotics or antiviral therapy. Depending on the patient's condition, it would be determined if they need admission onto a regular floor or the ICU.

Here's a good reference if you're interested in more information about encephalitis: http://www.ehealthmd.com/library/encephalitis/ENC_whatis.html.

Here's more about Dale in his own words:

My name is Dale Eldon, I am originally from Colorado Springs, and have spent most of my life in the Midwest. I am currently working on a four part sci-fi thriller series that takes espionage to the next level.

 In book one, two CIA agents fight to uncover the truth behind a terrorist related syndicate that seems to have their hands in a wide range of power across the country. Time is running out as the shadowy syndicate continues to practice dangerous experiments that could rip the space-time-continuum itself in half. The journey will go beyond personal sacrifice for a country; the world slowly through scientific manipulation is on the downward spiral to malicious hands.

 In book two, I will be focusing a lot on a FBI supervisory agent (profiler), who suffers from an unknown mental condition that is caused by one of these experiments. I had asked Jordyn to help me with some information on the medical side of what this character goes through.

 I am not yet published, but plan to be when I am finished writing my manuscripts. 

Medical Question: Police Notification

Dale Eldon poses this question: I see in TV shows and movies people who are shot or stabbed go to get medical treatment and yet they never deal with the police. Or they refuse to go because they are afraid that it will get reported.  If a person is taken to the ER with a knife wound or gunshot wound, would the medical staff have to report it to the police?

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Yes, we have to notifiy the police if a person is stabbed or shot. Now, knives can cause lots of wounds that aren't criminally motivated. Think about the person slicing vegetables and cuts their finger. Knife wound... not criminally motivated. We wouldn't call the police.

Another thing to consider... is the patient being truthful regarding their injury? If a person comes in with a knife stuck in their chest, we're likely getting the police involved even if they say it was an "accident". However, say a woman comes in with a defensive knife wound to the palm of her hand as she tried to keep her boyfriend from stabbing her, but she tells us that she cut it grabbing a knife from the bottom of a sink full of soapy water. If the woman doesn't have any other suspicious injuries, we probably wouldn't question her story.

It is true a patient might not seek medical treatment for fear of police involvement. The same can be true for child abuse injuries. A parent may not seek treatment or dealy treatment for fear of being reported to child protective services and/or the police.

See how the different variables can vary to increase conflict in your story?

Physical Restraint of Mentally Ill Persons

Isn't a medical scene more dramatic when you get to restrain someone? However, to ensure your scene is medically accurate, an understanding of the law and the limitations on using restraints is important. Of course, evil characters can do away with the law. That's your lattitude as a writer! I'm pleased to host Patti Shene and she shares her expertise from working as a psychiatric nurse. You can learn more about Patti by visiting her website at http://www.pattishene.com/.

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For a long time, restraint was used as a means to control the unpredictable and sometimes violent behavior of mentally ill patients. However, over time, the courts have recognized that these persons have an inherent right to freedom from inappropriate use of physical or chemical restraint.

The Supreme Court acknowledged, in the 1982 case of Youngberg vs Romeo, that the use of restraint severely inhibits personal liberty. They concluded the use of restraint should reflect “the exercise of professional judgment.” However, this statement encompassed a broad range of views that resulted in a nebulous interpretation.

Over the past decade, it has become clear that restraint and seclusion can legally be used only as a method of last resort when the patient is an imminent danger to himself or others.

Suppose you have a character who meets this criteria for “imminent danger to himself or others”. First, let me describe the type of physical restraint I am familiar with (pictured above).

Physical restraint consists of four leather cuffs placed around the wrists and ankles of the patient. The cuff has adjustable sizes and is fastened with a leather belt that passes through a metal loop on the cuff. The belt is then secured to the frame of the bed and locked in place. The belt can only be released, or opened, with a key.

The use of restraint should be considered a psychiatric emergency, and not used for convenience of staff or as a form of “punishment” for inappropriate or unacceptable behavior. There are many safety issues to consider when a patient is placed into physical restraints.

A nurse must always be present to assess the need for restraints. A patient can be physically contained by staff members prior to the arrival of the nurse, but only if there is an imminent danger to the patient or others.

Physical restraint without the use of an external device should adhere to strict guidelines. Cornell is one such method, a procedure that incorporates three staff members and greatly reduces the risk of injury.

The patient should always be physically contained face up to prevent asphyxiation or choking.

No cloth, clothing, or other restrictive material should ever be placed over the face during a restraint procedure.

Once the patient is placed into physical restraint, is imperative that circulation be maintained. If the caregiver’s finger does not fit comfortably between the cuff and the patient’s skin, the cuff is too tight.

A caregiver must check the patient at a maximum of fifteen (15) minute intervals.

The emotional needs of the patient must be met at all times.

Hydration and toileting needs must be met every two (2) hours.

A patient should never be left alone in a room with a door open after restraints have been applied. This would expose the patient to possible assault or injury by another patient.

The nurse must notify the physician and obtain a telephone order for restraint not later than one hour after the restraint has been initiated.

The dignity and privacy of the patient must be maintained at all times during the restraint procedure. Never is the patient to be teased, taunted, screamed at, intimidated, or in any way physically or verbally abused during the application or confinement of restraints.

If a personal issue exists between the patient and a particular staff member that could result in the violation of these basic rights, that staff member should immediately be removed from the situation.

In the case of child restraint in a residential child care facility, the parent/guardian must be notified as soon as possible that the intervention has taken place and the behaviors that led up to it.

Reevaluation of the patient in restraints, according to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is 4 hours for adults ages 18 and older, 2 hours for children ages 9-17, and 1 hour for children under age 9.

The patient must be released from restraint as soon as he/she is calm, cooperative, and able to maintain control. He/she must be able to commit to display safe behavior toward himself and others.

Several incidents across the country in recent years resulting in serous physical or psychological injury or even death have brought national attention to the issue of physical restraint. Do your mentally ill character justice by knowing the legality of how they should be treated when restraint is warranted.

Source material found at:

http://www.nasmhpd.org/general_files/publications/ntac_pubs/R-S%20RISK%20MGMT%2010-10-06.pdf

http://books.google.com/books?id=f_HYjDUArkMC&pg=PA87&dq=JCAHO+%2B+restraint+%2B+hours&hl=en&ei=nzvwTPb5OML_lge-v4zXDA&sa=X&oi=book_result&ct=result&resnum=1&ved=0CC0Q6AEwAA#v=onepage&q=JCAHO%20%2B%20restraint%20%2B%20hours&f=false

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Patti is a 1969 graduate of a state nursing school in Long Island, New York. Her exposure to state hospital surroundings led her to choose a career in psychiatric nursing. She is a Veterans Administration Hospital retiree and also worked at Colorado Boys Ranch, a psychiatric residential treatment center for several years. Retirement allows her to pursue her interest in writing. She currently fills the position of Executive Editor for Starsongs Magazine, a publication of Written World Communications for kids by kids.

Laurie Alice Eakes: The Midwife vs. Physician

I've been looking forward to historical author Laurie Alice Eakes post about how physicians overcame midwifes as primary caregivers for obstetrical care for some time. This has been a controversial issue in nursing for decades and I found this information very enlightening.

Physicians Take over the Practice

For centuries, even millennia, midwives served as the primary practitioners called in to assist in childbirth. Then a family of ?French Huguenots, established as “man-midwives” invented the forceps, an instrument resembling two spoons with a handle holding them together. The Chamberlain family kept this invention a secret for over a hundred years. When it was sold to or leaked to the public, other physicians began to use it and midwives began to lose their power over child birth, except in rural areas.

At first, midwives shunned the use of forceps. By law in some places and practice in others, they possessed small enough hands to pull out the baby in difficult births. After a while, though, laws changed and Midwives were not allowed to use forceps.  By the beginning of the nineteenth century, doctors were also using opiates to relieve the pain of childbirth.  Unfortunately, opium, as noted In Martha Ballard’s diary, A Midwife’s Tale, tended to prolong and even stop labor.  In the nineteenth century, ether and chloroform replaced opiates, especially after Queen Victoria allowed herself to be sedated during childbirth.

Lying –in hospitals came into practice, especially for poorer women. These were used as training fields for physicians wanting to deliver babies. Although germs were little more than a myth to medical practitioners until Joseph Lister and Louis Pasture proved their existence and harmfulness in the latter third of the nineteenth century, midwives and physicians made the observation that women who gave birth in hospitals suffered from childbed fever more often than did women who gave birth at home.  Women attended by midwives also had a lower mortality rate than did women attended by physicians.  After all, man midwives often went straight from an autopsy to the birthing chamber without washing their hands.

Why physicians strove to take over obstetrical practice is open to speculation.  Evidence, however, leads one to suspect that the motive was for financial gain.  Being men, thus having more power than women at that time, suppressing female childbirth practitioners was all too easy and financial lucrative.

Author’s Note: This article is adopted from a paper I delivered at the 1999 New Concepts in History conference under the title “Women of Power: Midwives in Early Modern Europe and North America”. My sources vary from newspapers, to diaries, to books difficult to obtain outside of a university library system, as many are hundreds of years old. If you wish to learn more, Google Books has some fine resources on childbirth practices in history.

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Midwives historic role in society began to fascinate Laurie Alice Eakes in graduate
school. Before she was serious about writing fiction, she knew she wanted to write novels
with midwife heroines. Ten years, several published novels, four relocations, and a
National Readers Choice Award for Best Regency later, the midwives idea returned, and
Lady in the Mist was born. Now she writes full time from her home in Texas, where she
lives with her husband and sundry dogs and cats.

Laurie Alice Eakes--Lady in the Mist from Revell Books, February, 2011. Read an Excerpt
at:
http://www.lauriealiceeakes.com/