Fun Video Blog Break: Lady Gaga

I can't say I'm a huge fan of Lady Gaga but this is some very interesting insight into what life's all about. Consider this as you're thinking through your New Year's resolution.

And it's clean-- no swearing.

Fun Video Blog Break: What is a Transatlantic Accent?

This isn't particularly funny but I found it pretty interesting-- why do actors from the 1930's and 1940's talk so funny? Definitely good for research if you write in the era.

Fun Video Blog Break: Cats and Dogs Breaking Bread

I thought this would be a super fun video to show on Christmas Day. A cat hosting a meal with a bunch of dogs. Watch it a couple of times to see all the funny details they've done.

Merry Christmas!!

Fun Video Blog Break: Jimmy Kimmel/Halloween Candy Theft

I'm all for playing pranks on my children but comedian and late night talk show host Jimmy Kimmel has taken it to a whole new level. Evidently, for four years running, he's asked parents to video their children's responses when they tell them, "We ate all your Halloween candy."

Some of the reactions are very interesting.

And if you need another helping. Here's the one from 2013.

Overall, with Christmas coming in a few days, let's work to teach children gratitude. 

Fun Video Blog Break: Have You Seen Jesus?

If you're a frequent follower/reader of this blog then you know every Christmas I take a two week blog break but share funny and/or interesting videos to celebrate the Christmas season.

I recently discovered comedian Chonda Pierce. This bit on finding Jesus-- as in Christmas lawn ornaments-- is pretty funny.

Enjoy.

Author Question: Delayed Death by Crossbow

Ben Asks:

Here's my scenario that I would appreciate some advice on:

I've got a 25 year old woman that is shot through the left calf and the upper torso (I was thinking, maybe having the upper body shot piercing her shoulder) by crossbow bolts made of wood in my fantasy novel. The weapons that shoot her are each one-hand-held, meaning that they can be aimed and fired with only one hand.

What I need to know is this:

1. Would this outright kill the character?

2. If yes, where on the average human female body can I have two crossbow bolts made of wood puncture that body in such a way as to negate instant death, but still leave months of recovery time for that character, if she gets the proper medical help fast enough?

For background information, the science level of the world I am writing is roughly the same level we have today in America and Europe, the same with this world's medical tech and knowledge.

Jordyn Says:

Thanks for sending me your questions.

1. A wound to the calf is unlikely to outright kill someone immediately. Any bleeding that's not controlled if brisk enough can lead to death. Infection is a risk with any wound-- particularly those that are caused from things (like arrows) that penetrate the body deep into its tissues leaving bacteria and other microorganisms behind.

The shot to the torso has more likelihood to cause death if it hits the right structure. On the left side of your chest are your heart, great blood vessels, and lungs. If the shot was more to the shoulder then an outright kill would be less likely and the risks above would be more prominent (bleeding and infection).

2. A shot to the calf and the shoulder have the potential to set your character back several months. If you don't want the character to die-- I would avoid having a shot to the torso. A projectile to any extremity can cause the bone underneath to fracture. Fractures typically take 6-8 weeks to heal.

If you didn't want to go with a fracture of the bone from the projectile-- you could have onset of infection (depending on how sick you'd want her to be for those months). Systemic infection can easily cause death. Local infection to the wounds can be problematic as well. You could also go with tendon damage to the arm or leg which would inhibit movement of the extremity. Healing and rehab of tendon and/or ligament damage can take months as well. Whenever an extremity isn't used because it's immobilized you always get muscle atrophy (muscle wasting) which causes weakness of the arm/leg, etc. It takes time to rehab that as well.

Good luck with your novel!

How Long Can Some Survive Without Adrenal Glands?

Jessica asks:

In my story idea one of the things my serial killer does is remove her victim's adrenal glands(she has illegal organ harvesters do this), then put him in an underground maze and see how far he manages to make it out of the maze before he collapses and dies. This character dies.

What I wanted to know was:

1. Is this idea realistic? Would he actually survive long enough to try and find his way out of a maze, or would he just collapse there and then?

2. If not, could I make it realistic somehow, for example, by having the killer give him some steroid hormones before dropping him in the maze, but then no more?

3. What would actual removal, as opposed to, say, Addison's disease, do to him? Like how severe would the effects be - would be just be a little bit weak and then deteriorate, or would he be really sick right away?

4. Something she does to another victim is render them completely deaf. How easily could she do this?

Jordyn Says:

The adrenal glands sit on top of your kidneys and release cortisol and epinephrine. You do have some of these hormones circulating at all times that will probably last somewhere between 2-4 hours. As to how long your character could last probably depends on how long and how much energy they would have to expend in the maze.

For instance, a five minutes stroll and he's out then he's probably alive at the end. However, if it's a long arduous maze and he's being chased by a serial killer, the victim will burn through their hormone reserves much faster and would be more likely to succumb to death more quickly.
 

Giving steroids could lengthen the amount of time they could live for. Patients with Addison's disease, where the adrenal glands aren't working properly, generally take supplemental steroids twice a day.
 

I would imagine the effects of immediate removal of the adrenal glands would cause the patient to be sick right away. In Addison's disease, the symptoms develop slowly over time because there is still some amount of these hormones being released. In surgical removal, there's no further release from the glands, just what the patient has remaining in their blood stream. And remember, surgery in and of itself, is a stressor to the body which would likely use up some of these hormones as well. I would do some reading on Addisonian crisis to get a clear picture of how soon and how sick the patient/victim would be.

It is easy to render someone deaf by puncturing the tympanic membrane and removing one of the ossicles (or one of three bones in your middle ear.) 
 Hope this help. Your book idea sounds very intriguing!

And shout out to Liz for helping me with this question. 

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.

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.

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! 

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.

How to Help a Loved One with Cancer

I was asked to post about this topic by my good friend, Dale-- what do you do when a loved one is diagnosed with cancer.

This is a situation where it's easy to feel helpless. Right now, two of my relatives and a good friend are dealing with cancer diagnosis-- all of them pretty serious.

My maternal grandmother also died of kidney cancer so I've dealt with this from both ends-- both as a family member and as a healthcare provider even though it's not my primary area of focus. I've been there when families receive the news that their child has cancer.

So, if I could offer any helpful tips, this is where I would start.

1. Realize when a family member first gets a cancer diagnosis-- they will likely not hear anything past those three words. "You have cancer." While your family member's mind is reeling, your job will be to remember (and I would even take notes) about what the doctor says next because the person receiving the diagnosis is in shock.

2. It is really helpful to have a family member go to the doctor's appointments to take notes. Keep a notebook and journal with everything the doctor gives you. Write down questions that you want to ask at your next appointment. It's easy for things to slip from your mind when your face to face with the doctor.

3. Get a second opinion. I do encourage second opinions for all major diagnosis and surgeries. Your provider should not be threatened by the fact that you want a second opinion. In fact, they should encourage it. You may not want to delay treatment, particularly if you've been diagnosed with an aggressive form of cancer, but that also doesn't mean you can't get one. It's not a betrayal of your doctor and it also doesn't mean you're going to leave them.

The purpose of a second opinion is to make sure the treatments are relatively aligned and you don't have a doctor coming out of left field.

4. Do things without asking. I know this may seem rude but what happens when people ask you for help? "No, I'm okay. I'll let you know if I need anything." And then, they never call. There are lots of ways to do this and with on-line sign up sheets so pervasive-- it's easy to set up. Set up a sign-up sheet for providing meals, cleaning the house, or giving caregivers respite breaks. If that seems overwhelming, show up at the door and say, "I'm here to clean your house. Where is the vacuum?"

5. Do fun things. A cancer patient doesn't always want to talk or think about cancer and they still want to live life. Don't stop calling or inviting them to do activities because you think they'll be too sick and/or tired.

6. Do cancer things with them. At the same time, don't be afraid to do "cancer" things with them. Go with them when they get their head shaved. Offer to go wig shopping with them.

7. Pray. This might seems trite but it has been proven through scientific study that patients that are being prayed over medically do better.

8. Be okay if they want to stop treatment. Hopefully, you won't face this point and your loved one with cancer will have successful treatment and go on to lead a full life. However, this isn't the case for everyone. Some patients make the decision to forgo treatment. They haven't come to this decision lightly. Be supportive and make the most of the time you have left. Let them know what they've meant to you.

What are your suggestions in how to help a loved one during a cancer diagnosis and treatment?

How Hard Is It To Do CPR?

Some of the questions you get asked as an ER nurse are very interesting. Some I can talk about . . . and some I can't. One fairly consistent question is, "How hard is is to do CPR on someone?"

It's hard people . . . flat out hard. 

The goal of CPR is to do the work that your heart does from the outside of the body. Keep in mind all that protects your heart from getting injured: layers of skin, fat, muscle and bone. All that has to be overcome to squish the heart enough for it to generate blood flow. 

Research has proven two things. The first is that CPR done effectively is the best thing that can be done to save your life if you go into cardiac arrest. Every minute you go without CPR your percentage of survival decreases precipitously. The second is that the effectiveness of one person doing CPR also significantly decreases after about two minutes which is why the American Heart Association encourages changing out those people doing compressions every two minutes. 

This story of an EMT suffering a stroke after performing CPR for 30 minutes highlights how much exertion a body sustains from performing chest compressions. 

So, there is a definite balance between doing effective CPR with the amount of physical strength you have on hand. 

Studies are also showing that continuous CPR, without pausing for breathing, is also increasing a patient's likelihood of survival. Some EMS organizations have gone to doing two continuous minutes of CPR immediately upon arrival and then going into the appropriate advanced life support protocol. 

The newest approach is what is called Pit Crew CPR. Just as in car racing where everyone has a defined role and becomes an expert at that role-- the same is true for this style of CPR. The importance of this method is that there is little pause in compressions. The concern with stopping CPR is that it takes anywhere from 15-30 compressions to get pulsatile flow again which is never good for the patient in cardiac arrest. 

In Salina, KS where they've trialed this their rates of return of spontaneous circulation (getting back a heartbeat) increased from 44% from 32%. That may not seem significant but it is a tremendous leap in terms of resuscitation medicine. Each of those points is a person living. 

Basically, in Pit Crew CPR, two people alternate compressions at either side of the chest. The person at the head of the patient manages the airway but initially the patient is placed on oxygen but there is not an emphasis on providing breaths as in traditional CPR. One person at a leg manages the defibrillator and a provider at the other leg establishes IO access (drilling an IV into the leg). 

After a few minutes of this style of CPR if the patient doesn't have a return of their pulse, they are placed on an AutoPulse and transported to the hospital. 

Proof's Problem with HIPAA

Proof (not to be confused with my debut medical thriller with the same title) is a medical drama starring Jennifer Beals as renowned cardiothoracic surgion Dr. Carolyn Tyler.

Dr. Tyler is recruited by billionaire Ivan Turing to investigate near death experiences (NDEs) as he is soon to face the other side due to a terminal cancer diagnosis.

Tyler is a skeptical atheist and believes death is the end-- even though she's had a NDE herself and longs to reconnect with her teenage son who died in a car accident.

Of course, Turing uses his wealth and a big donation to the hospital to obtain Tyler's cooperation.

Through the course of her investigations, nearly every religious permutation of the after life is explored-- past lives, reincarnation, and soul jumping among them.

The issue becomes when families become aware of Tyler's investigations and want information that in real life she should never disclose. They're clearly HIPAA violations. I've blogged extensively on HIPAA here, here, here, here and here!

Why is HIPAA so important? It is the law. It's what healthcare workers are instructed (pounded into the head) to protect every single day. It's not taken lightly. Medical people have been fired for violating a patient's privacy by disclosing healthcare related information.

However, the television show Proof seems to not understand what HIPAA entails.

In one instance, a mother who lost her son begins to believe his soul has inhabited another child's body because he has the same rare blood type, same rare heart condition, and was a piano playing genius. The mother latches onto him and offers to pay for his medical care.

It becomes a sticky situation because the mother who lost her child begins to overstep her bounds and Dr. Tyler begins to believe she's at risk for kidnapping this other boy over the loss of her son.

To prevent her from taking that step, she begins to list a litany of medical reasons why this patient isn't her son. The problem is, this mother has no right to any of this information. It is a HIPAA violation.

In another instance, Dr. Tyler convinces a wife to donate her brain dead husband's heart. Now, she has a vested interest in this happening because one of her patient's with a rare blood type (evidently everyone in this show has a rare blood type) has been waiting for a heart for years and is running out of time.

The wife agrees and the heart is transplanted but the patient nearly rejects the heart. When the wife of the heart donor catches wind that this has happened (she seems to be hanging around the hospital after the donation has occurred) Dr. Tyler gives her detailed medical information on how the patient who received her husband's heart is doing.

Again, this wife, even though she donated her husband's heart, has no right to this information. In fact, donor and recipient identities are highly protected. It's not that these families never meet but it usually happens months after and is coordinated by the organ bank and not doctors on site.

In fiction, you can break the rules. Healthcare workers can disclose medical information but they should also face a consequence for it just like we do in real life. The plus, it dramatically increases the tension which is always the goal of any work of fiction.

Book Review: Rush of Heaven

As a nurse, I've seen a few miracles in my career. Kids that lived that should have died. A co-worker of mine had a son and it was looking like he'd developed leukemia on several different tests-- and then a follow-up blood sample before they were getting ready to discuss treatment was clear.

As a Christian, I do believe that miracles still happen. I believe the birth of a healthy baby is a daily miracle. If you study even a smidgen about fetal development and what all must fall in to place for a healthy baby to be born-- you'd be in awe.

However, I do think most other miracles are rare-- the kind where someone is miraculously healed of a devastating chronic illness or a life threatening disease.

Rush of Heaven is the true story of Ema McKinley and how she was healed of Reflex Sympathetic Dystrophy or RSD. Ema developed RSD after a work-related accident where she hung upside down by her leg for several hours. One type of RSD can happen after traumatic injury and there becomes miscommunication between your peripheral and central nervous system as well as a heightened inflammatory response.

What happens in response to this injury can be muscle atrophy and tightening but the syndrome can extend beyond the injured extremity-- as it did in Ema's case-- leading her entire body to become significantly disfigured to the point where she was nearly bent all the time at a ninety degree angle.

Then one night, about eighteen years after her accident, Ema says she received a visit from Jesus and is cured of her RSD. She is healed to the point where she is no longer wheelchair bound and can actually stand up straight. She becomes independent again.

The story is very interesting and the pictures in the middle of the novel are, literally, worth a thousand words. It was very interesting as a nurse to read about all the difficulties Ema had navigating the healthcare system (payment issues complicated by a workman's comp case, a multitude of doctors-- some better than others).

One consistent theme I've noticed that runs through these health related miraculous healing stories is that these patients never "curse" God. All through their illness, they continue to speak their faith in bold ways. Imagine the impact that has on nonbelievers when you're so sick and continue to praise God with every breath-- and then can speak to the healing He provided you.

If you're interested in reading about miracles or even about RSD in particular, I think you'll love this book.

I was provided a free copy of this book to review. A positive review was not required.  

Author Forensic Question: DNA and Donated Blood

Today, I'm posting a forensic medical question I had for Amryn Cross.

Jordyn Asks:

Can you tell if blood from a crime scene is from a donated pint of blood? If so, how?

Amryn Says:

You can actually tell the difference. A donated pint of blood will only have red blood cells and not the other components of blood (white blood cells, platelets, etc.). When the DNA from the donated blood is tested, the scientist would probably think it odd that they got little to no DNA yield (red blood cells don't have nuclear DNA). They might chalk it up to degraded blood, or they might look at it under the microscope and find only RBC, which should make them suspicious. But probably the first indicator is that the blood at the crime scene would not clot if it were from a donated unit. The investigator may or may not pick up on that, but a crime scene tech probably would.

Jordyn Asks:

What about a pint of whole blood? Would it still be the same? Would small amounts of dry blood give DNA?

Amryn Says:

Whole blood would give DNA results but wouldn't clot, so that would be something they would have to pick up on at the crime scene. If it was suspected and they wanted it verified, tests could be done for the preservatives in the bag.

Yes, if they were just droplets, they would still dry over time. And as long as it's whole blood, it will give lots of DNA.

************************************************************************

Amryn Cross is a full-time forensic scientist and author of romantic suspense novels. Her first novel, Learning to Die, will be released in September. In her spare time, she enjoys college football, reading, watching movies, and researching her next novel. You can connect with Amryn via her website, Twitter andFacebook.

Author Question: Nursing 1940's

Anonymous Asks:

First and foremost, I have to say that I am in love with Medical Edge. I've been spending a lot of time on it lately because I enjoy studying medicine and also because I am starting to do research for my novel. It's set in 1939 through to 1943. I have three questions for you.

One of my main characters is a nurse in Sioux Falls, South Dakota. I want to be able to write her doing her job correctly. I was wondering what kind of equipment they used, how they used it, and for what illnesses (No need to be extremely specific here, I think). Also, what would her responsibilities be within the hospital? Would she rotate through all the wards or do/did nurses have particular specialties like physicians?

Jordyn Says:

Thanks for your compliments on my blog! Glad you find it helpful.

Nursing in your time frame of 1939-1943 would have looked a lot different than it does today. They definitely wore uniforms and caps. Doctors would have been formally called "Dr. Smith" versus using first names like we do now (although not in front of patients).

Nursing work was viewed as inferior to the physician meaning—you do what the physician says. Now, a nurse’s input is more respected. Doctors and nurses realize they can't work separate from one another.

Nurses likely didn't specialize then like we do now and there was likely not a lot of physician specialties either as there weren't any intensive care units or emergency departments until the 1970s. Equipment would have been non-existent like the heart monitors and stuff we now use. Read through this info to get a general feel of how the floors or "wards" would have been split up.

This link is from Britain but would probably have some cross-over to the US. Here is a link to some personalized stories from people who nursed during your time frame. I would read through these for the 1930's and 1940's to get a feel for what their jobs were like.

This is also from the UK but should provide some insight. 

Question:

Another one of my main characters goes off to fight in the war. How severe would an injury have to be for him to be discharged? Presently, I have a situation designed where he is aiding a family out of a bomb shelter; there is an unexploded shell nearby, and a child accidentally kicks rubble at it and sets it off. Big boom, main character loses part of his leg and half of his body is burnt. I'm also thinking that he loses his hearing. Would this be plausible?

Jordyn Says:

I would search military discharge related to a medical condition two ways. One—what medical conditions are prohibitive for military service and those conditions that would lead to discharge.

 I found this list, but you could probably find more and if it's the 1939-1942 time frame it may be different than those that cause discharge in these times.

The injuries you list related to the bomb blast are realistic and I think would be enough to cause his discharge from the military as well.

I contacted a cousin of mine who serves in the medical corp of the military and he said to look at AR 40-501 which is the standard of medical fitness. Basically, if you couldn't do what's listed than you could be discharged from service. He did say that there are personnel who are still serving who have amputated limbs.

Question:

Lastly, my nurse has a patient, a woman in her 40s or 50s, who she loves with all her heart. I want this patient to die. What would be a good way to kill this woman off? I need her to have been in the hospital for around four years. I also want to have her weak but able to speak with my other characters. What's a good malady for this situation?

Jordyn Says:

This kind of criteria would mean the character would need a chronic illness that's debilitating. You could look into multiple sclerosis, Lou Gehrig's Disease, Huntington's Chorea or some of the autoimmune disease like Lupus or Sarcoidosis.

These diseases fall on a spectrum (more MS and the autoimmune diseases) but Lou Gehrig's Disease and Huntington's Chorea lead to neuromuscular wasting, etc that does lead to death and there is currently no cure.

In that time frame you're looking at you'd have to determine if they were able to diagnose these diseases. To do that you could Google search "When was Lou Gehrig's Disease discovered?" That should get you in the ballpark to know if the medical community knew about whatever disease you chose for your time frame.

Keep in mind—it would be highly unusual for someone to be hospitalized for four years straight.

Pediatric ER Nurse Warning: Amber Beads for Teething Relief

Working in a pediatric ER, you see parents do lots of curious things. In the last three months or so, I began seeing a fair number of infants come in with these beaded amber necklaces around their necks.

One of the main goals in nursing is accident and death prevention. That's why we talk about using helmets and wearing your seatbelt. Honestly, some of us would like to see trampolines outlawed because they are responsible for so many childhood injuries.

We also don't like to see anything around a child's neck that would pose a risk for strangulation. Things like this would include wearing a sling at night. We generally don't recommend this for concern that the child may get caught up in it and get strangled to death. 

The first time I saw these beaded necklaces-- I was surprised at how heavy they were. I asked the mother why the child was wearing them.

She said, "Oh, they're for teething."

Hmmm.

I explained my concern to her that I thought they posed a significant strangulation hazard and whatever perceived benefit they had for teething pain would not outweigh this risk in my mind.

And she promptly removed them.

But now I see many infants coming in and wearing these so I thought it was time to blog about my concern for these infants' safety. 

 These amber beads seem to have originated in Europe where the claim is that when the beads are warmed up by the infants skin, they give off a pain relieving substance that is absorbed through the skin.  

This article provides an excellent overview of how these claims are categorically false. 

In fact, Health Canada issued a safety warning about the risk of these amber beaded necklaces use in children and France and Switzerland don't allow them to be sold in pharmacies. 

This article highlights a near miss of a toddler who became entangled in her necklace while she napped. 

Point being-- nothing should ever be placed around your child's neck regardless of any claims for perceived health benefits. 

Commentor Question: Lacerations and Plastic Surgeons

This blog is generated from a comment on this post: Medical Myth: Lacerations Need a Plastic Surgeon.

I do read each and every comment to the blog. Usually, I don't comment on real life medical scenarios but I thought this had several good teaching points that could serve the public good.

The comment:

I just brought my 5 y/o into an ED with a puncture wound to the center of his forehead through which you could see his skull. I thought the attending would close the wound, but the resident did under supervision. First year, and it was late July. What are the chances of a good outcome? The attending had to tell the resident that knots were backward, etc. Should I have insisted that the attending close, or that they call plastics? It was a large urban Children's ER.

Jordyn Says:

Thanks so much for leaving this comment and I hope you see this post.

As a mother and a nurse, I get the parental anxiety around closing lacerations. The truth is that anything that requires sutures is going to leave a scar. That's life. Now, how big or thick the scar is depends on many factors. How it was closed. There is a learning curve to closing the skin. Lacerations can actually be closed too tightly which can be as problematic as not bringing the edges close enough together.

That being said, there are many other factors that determine how the scar will look. Does it become infected? How does the patient normally scar? Some people genetically develop very heavy scarring (called keloid scarring) and there's nothing we can really do about that. Also, after healing, how much is it exposed to the sun?

Now, should you have allowed a resident to suture your child?

From the medical side-- students need to learn and must practice, at some point, on live patients. I'm glad this first year was being monitored during the procedure. That's what should have happened. Knots being tied backwards and needing to be redone doesn't mean you'll have a bad outcome. Experienced physicians redo sutures all the time. It's more the final closure that's important.

From my nursing/mother standpoint-- you have the right to refuse a resident practicing on your child. If you are uncomfortable then absolutely speak up and state your request plainly-- "I'm sorry, but I'd like an attending to close this laceration."

Some people are uncomfortable with a nurse practitioner or physician's assistant doing a laceration repair and request an attending. Keep in mind, that mid-level provider may have more experience than your attending physician. They may have been in practice four times as long! So maybe ask how many years they've been practicing as an attending before you pass over on a mid-level provider.

If you feel that you can't make this request to the doctor directly, then you need to tell your nurse who should advocate for you.

Should you have insisted on a plastic surgeon? The truth is that pediatric ER providers close lacerations every day on moving targets-- we don't commonly sedate kids for simple laceration repairs. Plastic surgeons are generally only utilized for complex laceration repairs and would honestly be annoyed to come to the ER for a simple repair.

If you don't like how the wound healed and the scar it left behind then you can consult a plastic surgeon to investigate a scar revision.

Hope this helps.

Author Question: Surgical Spleen Removal

Amanda Asks:

I have a character who was shot in the side, not life threatening, but he had to have surgery to remove his spleen as well as the bullet because some rib fragments damaged his spleen.

My question is how long would he be in the hospital after surgery? I'm sure when he first comes home he'll be getting around in a wheelchair or something while he heals and gets his strength back. When could I plausibly have him on his feet slowly walking around? I don't want any dramatic complications with his injury or anything. He's going to heal up great and be perfectly fine afterward.

Jordyn Says:

I ran this question by some of my nursing cohorts who focus in adult surgery.

Having your spleen removed would require a couple days stay in an intensive care unit. This would be due to risk of post-surgical bleeding and concern for infection.

The surgical nurse I spoke to said these patients are up and walking by the time they come to the floor so there would be no need for the character to use a wheelchair.

Once research point that is helpful with this question is that you can Google search for discharge instructions regarding many kinds of operations. For this one, I searched for Home Care Instructions after Spleen Removal. This document gives excellent information that can be translated into your novel.

For instance-- how long the patient should expect to have pain. Driving and lifting restrictions which can help determine what they would physically be capable of in your novel.

FYI-- patients who have had their spleens removed are at more risk of serious infection. Your spleen is part of your immune system. So some infections that would normally not be a big deal for the general population can be life threatening to those who have had their spleen removed.

Author Question: Management of Unusual Patients

Amy Asks:

I hope you can address this. Or, if not, point me at a resource that can. I am writing a short horror story in which a patient complains about not being able to get clean. She washes and then within an hour, she's dirty again. And if she doesn't wash, the dirt just accumulates. She's a magnet for dirt. The patient is not complaining of Morgellons and has no history of drug abuse. Neither does she have a history of (or current problems with) OCD behavior.

My assumption is that the doctor would review proper hygiene with her and then find a tactful way to make a referral to a psychiatrist or psychologist. Is that correct?

What questions would the doctor ask? What language would she use when documenting this meeting? And what would she do when more patients start presenting with the same complaint?

In my story, the complaint becomes a pandemic. With this illness, it's always possible to wash away the dirt, you just can't keep it away. What are the long-term health consequences of not being able to remain clean? I know that it will increase the possibility of local infections but can you become ill from simply being dirty? (This hypothetical illness would only attract dirt, not pests. But would being dirty make it easier to attract and harbor fleas, ticks and lice?)

Thank you for any help you may be able to provide me!

Jordyn Says:

Wow, Amy. This is a very intriguing question.

I’ll have to take it from an ER nurse's standpoint. A patient who presents with a complaint of dirt accumulation despite showering definitely raises some eyebrows. If the patient is not expressing wanting to kill themselves or others—then there’s no immediate need to involve psychiatric services. The doctor may say something akin to, “I don’t think this has a medical cause. I think it might be best to follow-up with your regular physician for a referral to a mental health professional.”

Mental health evaluations are rarely done in the ED by an ER physician. These services are likely contracted out or handled by someone else other than the ER physician. You may have heard this phrase about ER docs, “Knowledge of all. Master of none.”—Meaning they have a significant knowledge base but are not specialists. Their job entails identifying a true medical emergency and managing that—so in absence of that, they’ll refer on.

I would say localized infection from open wounds is the biggest risk. As far as attracting other pests—what kind of environment do they live in? Just because you have extra dirt on you doesn’t mean you’ll have lice, etc.

I also ran you question by friend, author and ER physician Braxton DeGarmo.

Braxton says:

I cannot think of a single scientific way that someone could become a dirt "magnet." As such, the idea of a pandemic in which people can't keep clean would very much require some sort of fringe science explanation and to pull the plot off you’d have to build that idea in bits and pieces to make it believable—much like Crichton did for re-building ancient DNA from amber to clone dinosaurs.

Now, as a psychiatric condition, this is very plausible. I've taken care of people who thought they were shrinking and that snakes were under their skin. All of these were manifestations of a psychotic break. So, yes, a tactful referral to psych would be warranted. It would be easier to come up with something that causes such a psych pandemic than one where people keep attracting dirt and grime.

The problem, though, is that everyone's psychotic break would be different. So, again, you’d have to build some case where they all share OCD or the opposite, an attraction to dirt to where they purposefully seek to get dirty. Both scenarios will require some work to build scientifically plausible causes.

Perhaps, there could be an illness that leads to a specific deficiency and the dirt they instinctively "collect" somehow fills this need and is absorbed through the skin. To the casual observer, they just look dirty, but a closer look finds common mineral “X” or whatever, within everyone's grime. And it's the only common factor, thus leading the protagonist or someone to figure it out.

Most folks have heard of people with certain deficiencies sharing a common trait, such as pica to fill an iron deficiency. So, this might be an easier way to build plausibility.
 

As for the specific questions, yes, local skin infections might become more of a problem, but not necessarily any systemic issues. Likewise, with fleas and such. Degree of skin cleanliness has nothing really to do with such infestations. 

Best of luck with this novel! Very intriguing idea. 

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.