Important Notice to All Readers!

Hello everyone!

I'm officially moving this blog over to WordPress. You can find and subscribe to the WordPress site here. This also means I'll be discontinuing the FeedBlitz Feed for these posts after October 1st, 2016.

I'll be continuing all the great content you've found here on WordPress and I think it will offer a much better search engine for my posts as well as a better reading experience.

Hope to see all of you over there.

Posts will resume over at WordPress the week of October 2nd, 2016. and I'll be offering some great surprises for readers who follow me on WordPress.

Hope to see you there!

Sincerely,

Jordyn Redwood

 

Is a Patient With a Concussion Admitted to the Hospital?

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

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

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

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

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

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

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

Castle: Dying From Medical Inaccuracy

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

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

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

There are TWO major problems with the above assessment.

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

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

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

Author Beware: The Right Patient Placement

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

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

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

Well, yea, just--- no.

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

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

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

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

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

Author Beware: Provider Scope of Practice (EMS)

Here I am, happily reading along one of my favorite mainstream suspense authors, when a glaring medical mistake takes me right out of the story. Bummer! Now I'm wondering how long it would have taken this well known author to make one phone call to determine if this situation was plausible or not.

The scenario: The hero in our story is injured but doesn't want to be transported by EMS to the hospital. He's got other important things to do-- like catch a killer. Awesome. EMS has him sign a release form and he's on his way BUT the EMS team has given him an oral dose of a narcotic and two to take in the future when the pain comes back.

Did you hear that? That was steam billowing out of my ears.

This is a very common mistake authors make-- issues that deal with scope of practice. I've blogged about it several times. This post has links to several others that just deal with scope of practice.

In simple terms, scope of practice is what a health care provider can and cannot do. EVERY licensed health care provider (a nursing assistant, a nurse, an EMT, a paramedic, a physician, a physical therapist, a pharmacist) has a scope of practice that is governed by their licensing board-- whoever that might be. These governing boards determine the rules of practice. If the licensee does something outside of these rules they can be brought up on disciplinary action and even potentially lose their license. Scope of practice rules can vary from state to state.

In short-- it's bad to operate outside your scope of practice.

For instance, this document gives a pretty detailed overview of the medical treatments different EMS professionals can do.

The first problem with the author's scenario is that EMS professionals do not carry oral narcotics to give to patients. Only IV and those that can be administered nasally.

The second problem is that EMS professionals not only operate under scope of practice laws but also medical protocols which outline the things they can do in the field and under what conditions. In fact, here's a whole document that lists the EMS protocols for one hospital in Colorado that would give a nice overview for what likely happens in the US. There will be differences state to state but you could reasonably generalize from this.

Essentially, a paramedic giving a patient (who is refusing medical treatment) three doses of an oral narcotic (which he doesn't carry) is a serious violation of his scope of practice. Only a few medical roles can prescribe oral narcotics and dispensing oral narcotics is the role of a pharmacist.

Authors should take scope of practice as seriously as medical professionals do because though your book might be fiction-- the public will take it as fact.

Seven Medical Posts for Authors on Blood Loss and Bleeding to Death

How fast a person can bleed to death is a very common question among authors and I've done several posts on the topic. About a month ago, I got a comment asking a variation of the question.

It's as follows:

Although I've worked in an animal clinic for years, I wasn't sure how much of what I'd seen there translated to the human side. I'm currently editing someone's manuscript and the injuries in a couple of scenes struck me wrong enough to do some digging before revision. A couple of things I'm still looking for is how long a person remains conscious with arterial or venous bleeding (in one scene, this is from a femoral injury) and whether/how much accelerated heart rate from exertion speeds bleeding?

Jordyn Says:

It's hard in medicine to give actual time frames. The best demonstration I ever saw of how fast it took to bleed out was from a physician that drilled a hole into a two liter bottle of pop and then squeezed it mimicking a heartbeat. He said the size of the hole could be equated with an injury to the popliteal artery (which is behind your knee) and that bottle was empty in about two minutes.

Devastating injuries to larger arteries (your aorta for instance) can cause the patient to bleed out (hemorrhage or exsanguinate) in 1-2 minutes. It's fast. For instance, if you rupture your descending aorta in a hospital and they know exactly what is wrong with you, and even have a couple of IV's in place, your chances of survival are still not awesome.

Some general rules:

Arterial bleeding is faster than venous bleeding. This is because the pumping action of the heart causes more brisk blood loss. That being said, all bleeding can lead to death if not controlled. It's probably safe to assume that bleeding from an artery without any intervention could lead to unconsciousness in one to three minutes and death in under five minutes.

Uncontrolled venous bleeding might take upwards of twenty minutes or days. Again, if not controlled in any way. Again, this could be variable. The author has a lot of leeway.

Does a fast heart rate accelerate bleeding? Yes. The faster your heart beats, the more blood spills, particularly from an arterial bleed. This is a double edged sword because your body will compensate by increasing your heartbeat during blood loss to compensate for all those red blood cells on the pavement and not in your body carrying oxygen.

Here are other posts on the topic of blood loss:

Author Beware: Arteries vs. Veins.

Author Beware: Arterial Bleeding vs. Venous Bleeding.

Killing my Arteries: Truth or Die by James Patterson. Can IV drugs be given in an artery? 

Pregnant Woman Bleeding to Death.

Pregnant Woman Bleeding after Delivery.

Bleeding to death from gunshot wound to the arm and back? What organs can be hit to bleed but not be lethal?

What other questions do you have about characters bleeding to death?

Rape Kit Testing

Stan Asks:

My question for you is would a rape kit routinely be used to test for evidence of chemicals found in a condom in addition to DNA or would further tests be required? My plot has a woman getting even with a man by having her girlfriend have sex with the guy (he’s using a condom). She then gives the material to her friend who applies the sperm and claims she was raped.

Amryn Says:

Rape kits are routinely tested for the presence of semen and sperm and maybe saliva depending on the story the victim gives. Chemicals found in spermicide and other condom components aren't something an analyst would test for. Depending on how long of a time lapse between intercourse and the woman applying the sperm, it's possible the spermicide on the condom would have already degraded the sperm to the point that it isn't detectable, but that would only occur after a long time.

 More likely, when DNA testing was performed, it would yield a mixture of 3 profiles: the man, the woman's friend, and the woman. This is because the woman's friend's profile would likely be present on the condom from the intercourse she had from the man. This might raise a red flag but it would be up to the investigator to look into it further.

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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.

Can a Pregnant Woman be an Organ Donor?

Carol Asks:

Can a pregnant woman be an organ donor?

Situation: The woman is in her first trimester. She's been in a car accident and the pregnancy terminated itself as a result of the accident. She's been kept alive on machines for several days with no hope of recovery. Can she donate organs?

Jordyn Says:

I don't see why not because she's technically not pregnant anymore. My only drawback is if law enforcement thinks the death is suspicious in any way and it becomes a corner's case for some reason.

That being said, I do find the question intriguing-- like could a pregnant woman who is further along still donate organs? My gut instinct would be that they would keep the "body" alive until the infant was viable or deliver if past 24 weeks. Then the woman should be able to donate organs.

Alleged Patient Exposure to HIV/Hepatitis After Drug Diversion

I want to start this post by saying "Oops, it happened again." The problem is, I shouldn't have to blog about this topic considering how serious it is and the potential risk to patients.

I live in Colorado. In February, 2016, it hit the news that one of the Denver areas largest hospital, Swedish Medical Center, was testing close to three thousand patients for possible exposure to HIV and Hepatitis after a surgical tech was suspected of diverting drugs.

What is drug diversion? Drug diversion is using a narcotic for anything other than its intended use. The most mildest form is not wasting drugs properly. It requires two licensed personnel to waste a drug and sometimes you just can't find another person at that moment and then you forget. Not excusable but understandable. The most serious form is healthcare workers using the drug themselves and not giving them to the patient or using the "waste" or overage for themselves.

The problem is, a relatively similar scenario happened at another Colorado hospital in 2008 and 2009. This was the case of Kristen Parker, a surgical tech who is currently serving a thirty year prison term for infecting three dozen patients with Hepatitis C. She was stealing unlocked Fentanyl set aside for surgery, injecting it into herself, and then drawing up saline into the same syringe where then an unsuspecting provider injected it into the patient causing transmission of the virus.

In fact, one of the anesthesiologists involved in this case went public and even wrote a novel based upon her experience. This wasn't a quiet news story.

In this blog piece from The Daily Beast in February, 2013, Gorman states:

“At that time, we didn’t think about locking drawers,” she says. “No one ever told me I was doing anything wrong. If there were rules to enforce locking the drugs up, they were not enforced.” Rose has said it sent memos to its anesthesiologists in 2001 and again after Parker’s crime, warning them “never leave controlled substances unlocked or unattended.”

In light of this incidence, it is unbelievable to me that a case of suspected drug diversion involving a surgical tech could happen again in this state and it makes me wonder if potentially the same process of drug diversion was used as Kristen Parker employed-- unsecured narcotics awaiting injection for surgical procedures.

The tech, Rocky Allen, has been arrested and has pleaded not guilty. Thus far, it appears two patients have tested positive for Hepatitis B.-- although the hospital currently denies they transmitted the virus as part of this case.

So please, hospital OR's everywhere, can we please develop a system where narcotics can be dispensed safely to surgical patients?

EMS and ER Response for an Unconscious Female Trauma Patient

Ginger Asks:

I have a 23-year-old woman with an obvious head wound (she got hit with the butt of a gun, but the first responders don’t know that) who’s been outside in 20’ish degree weather without a coat for an undetermined amount of time. She’s unconscious. Obviously an IV is started, but what else will paramedics do to treat her? Warming blankets? What would happen when she got to the ER?

Jordyn Says:

Thanks for sending me your question.
 

EMS Response:

For an unconscious patient with an obvious head wound, but is unable to tell how her injury happened should be placed in C-spine precautions. That means C-collar and backboard. IV-- yes. And warming. They'd get a set of vital signs, put her on a monitor and then do a full assessment to look for other injuries.

Checking her blood sugar is warranted because why is she unconscious? Did the injury to her head happen because she passed out from low blood sugar? Or is it too high? Looking for medical alert bracelets as well. They'd probably key in on a good neuro exam like are her pupils equal and reactive to light? What type of stimulation does she respond to (voice, touch or pain?) They might even give a dose of Narcan to rule out opiate overdose (like heroin.)  

In the ER:

Full assessment as above and we'll look for other injures. We'll maintain C-spine precautions. She would be completely undressed (again-- looking for other injuries.) We have a better ability to monitor temperature so we'll know exactly where she's at and work to rewarm her. This could range from warm blankets to warming lights and heated IV fluids. Full set of vital signs. We'd place her on the monitor as well to watch her HR, breathing and oxygen levels continuously.
 

As far as testing and procedures go, if she remains unconscious, I would say the following:

1. Spine X-rays. 

2. CT of the head (to look for bleeding, stroke, tumor.)

3. Labs: Full metabolic panel (this will check blood sugar again), complete blood counts, alcohol level, aspirin level, Tylenol level. Tylenol and aspirin are drugs people will overdose on that can be very serious.

4. Urine toxicology panel (this would pick up on major substances of abuse but not everything.) Also urine pregnancy test. 

5. ECG. To see if a heart arrhythmia or heart attack could be an explanation for her passing out.
 

Unless we know the exact mechanism of the injury we have to consider both inflicted wounds from another person but also that she might have just passed out and hit her head and what the reason for that might be.

If she's truly unconscious and doesn't respond to pain-- she'd likely get a tube in every orifice as they say and they'd have to consider whether or not to intubate her (put a breathing tube in) to protect her airway. If that happens, then NG tube (placed probably through the mouth into the stomach) and a Foley catheter which drains your urine into a bag.

If she's somewhat responsive but immediately drifts off-- they could hold off on tube placements, check the tests I've listed, and give her some time to see if she wakes up on her own if she's breathing well on her own.

Surviving a Shipwreck Post Hurricane

Jocelyn Asks:

I’ve written a hurricane scene, and I don’t think I got the medical details right, so I thought I should check with you.

I have characters abandon their ship as it goes down. They stay afloat using planks of wood, but just holding on to them in the water, not lying on top of them. This takes place in the Gulf of Mexico in September.

When they are rescued several hours later, what will their condition be? Will they be fully conscious? Would they be cold? My heroine’s brother dies in the water, so is that enough to put her into shock, along with the ordeal of surviving the hurricane?

While one character is floating in the water, a piece of bowsprit breaks off from another ship and flies through the air, hitting him. I want to injure him enough for him to lose his grip on the plank he’d been holding onto, but I don’t want him to die from this injury. I was thinking if the wood hits him in the arm or shoulder, either breaking his arm or dislocating his shoulder, that would be good enough. Is that realistic though? Or does it just depend on the angle and the velocity?

Jordyn Says:

First thing to determine is the temperature of the water in the Gulf of Mexico in September. I found a table from the National Oceanic and Atmospheric Administration with water temperature tables for the Gulf of Mexico  that lists temperatures for September in the mid to upper 80s.

The next question is how long does it take hypothermia to set in when you’re submerged in water at this temperature?

This table gives an "indefinite" time frame where as it lists time limits for cooler water temperatures. For instance, in water that is 32.5 degrees, it gives a time of under fifteen minutes for exhaustion or unconsciousness to set in.

Considering this information, your characters should be conscious when they are rescued. Just because they don't die from hypothermia doesn't mean there aren't other risk factors like getting eaten by ocean creatures, sheer exhaustion, or dehydration and malnourishment from not eating or drinking.

If the rescue is under twelve hours, I'd imagine they would be in pretty good shape. An adult can probably survive three days without water but it would also depend on what environmental factors are present. You'll dehydrate faster in sunny weather than a cool, overcast day. I would imagine they would still feel cold. Your normal body temperature is 98.6. Hot bath water ranges from 99-104 degrees. Bathwater temperatures vary depending on the source and hot tubs are around 104 degrees. So, being immersed in 80 degree water will still feel cool. Patients getting room temperature IV fluids always get chilly.

Emotional traumas like the death of a loved one AND surviving a cataclysmic weather event can put someone into shock.

I think it's reasonable to give your character a fracture after being hit by the bowsprint. But then he'd be unlikely to use that arm at all to hold onto things but it should be a survivable injury if a closed fracture and the rescue is fairly soon. I would think an open fracture, where the bone comes through the skin, would put him more at risk for complications and lower his survivability if the rescue is delayed by a few days or more. 

In What Form are X-rays Read?

Dawn asks:

Are x-rays still on film and put into a light box? Or are they digital, on a computer screen.

Jordyn says:

Yes, x-rays are digital now and viewed on computer screen. Paper print outs and discs are given to the family. Paper copy if it's just showing the parent "this is your kid's fracture." A disc if another doctor will need to look at it. Even when we get films from other area hospitals they are on a disc. I haven't seen films in close to ten years.

If the novel is set in the US this is probably a safe assumption but may not be for developing countries.

What's The Ruckus About Zika?

If you've listened at all to the news lately then you've been hearing about Zika virus and the concern it's causing about a possible link to microcephaly (babies born with small brains) from women who were infected during their pregnancy. I knew it was time to blog about Zika when I overheard another woman at the salon claiming that engineered mosquitoes were responsible for the Zika outbreak. Surely, this was a conspiracy theory but my suspense author brain was warmed up and not just because I was under a set of heat lamps.

I had to investigate (and make lots of notes for future books.)

Zika is a flaviviridae and is in the same family as Dengue, West-nile virus, and Hepatitis C. Zika is transmitted via mosquitoes so an infected person gets bit, and when that same mosquito bites another person, transmission can occur. 

Only about twenty percent of people infected with the virus will show symptoms. It's unknown how long the incubation period is. An incubation period is from the time of infection until you show symptoms. 

Symptoms can include fever, rash, joint pain, headache and conjunctivitis lasting up to one week. Deaths related to Zika virus are rare. 

There is no current treatment for Zika other than prevention-- which in this case is not getting bit by an infected mosquito. So repellent, mosquito nets, etc. The above information comes from the CDC website which you can further read here. 

 Zika was first discovered in 1947 in a Rhesus monkey in Zika Forest, Uganda. There have been previous cases in Uganda, Tanzania, and Nigeria before it broke free from Africa into other areas. It hit Chile in 2014 with cases until June 2014. And then it disappeared.

In May, 2015, Zika was confirmed in Brazil. The largest concern is Zika infection in pregnant women where it seemingly is causing arrested brain development in unborn babies or microcephaly. It's unknown what percentage of infants, if any, develop microcephaly when the mother is infected with Zika during her pregnancy or at what point in the pregnancy this would be concerning for developing the congenital condition.

Brazil is where there was a noted spike in cases of microcephaly. Keep in mind, the link between Zika and this birth defect is suspected but scientifically unconfirmed. Some are postulating that the increased cases are due to hypervigilance and a broad screening net. The Brazilian government stated on January 27th "that of 4,180 cases of microcephaly recorded since October, it has so far confirmed 270 and rejected 462 as false diagnoses."    

And, according to this well laid out article, the genetically engineered mosquitoes aren't the cause for the spread of Zika. However, I do see the possibility of a future post and a very good basis for a medical thriller in the future.

What do you think about Zika? Are you worried about it? 

How Likely Is It For A Parent To Be an HLA Donor Match for Bone Marrow?

Anonymous Asks:

How likely is it for a mother and an uncle to be bone marrow donor for her child? What can a donor expect if picked for donation?

Jordyn Says:

I found this article you might want to take a look at that specifically talks about the odds of a person being a match for their child. A sibling has the best chance at twenty-five percent. A parent of a child only has a one in 200 chance to be a match. Why is that? Because a child gets genetic information from two parents and it’s unlikely that these parents would have the same genetic makeup as their child. So the likelihood of both the mother and a biologically related uncle coming up a match would be pretty slim. I think both being a full match isn't possible statistically.

This article goes into detail about what a donor can expect. 

A Medical Rebuttal of Amazon Review: Dianna Benson

It's hard as an author to get bad reviews-- and it's hard to know what to do about them. Generally, I personally feel everyone's entitled to their opinion about my work. As Elizabeth Gilbert states in Big Magic-- my job is to get my work out there and everything else is not my business.

But it's hard, particularly when a reviewer remarks about a medical inaccuracy in your novel and you are a medical expert. And since this blog is about medical accuracy in fiction, I'm hosting Dianna Benson to talk about her experience with just such a review. 

Welcome back, Dianna.

A few months after my first novel, The Hidden Son, released in 2013, a reader/fan contacted me to inform me a review was posted on Amazon with incorrect medical comments. The person who wrote the review stated it’s not possible for someone who suffered brain damage from head trauma to recover and later become a police officer. Recently, an MD wrote a review on Amazon stating and explaining how that review is medically inaccurate – thank you, Robert Littleton, MD.

As an EMT for eleven years, I have firsthand medical experience and knowledge, especially with trauma, and I implement that into all my suspense novels. As Dr. Littleton stated, the human brain can heal from temporary damage (thus not all brain damage is permanent.) In The Hidden Son I briefly explained the character’s injuries and recovery, and in Persephone’s Fugitive (Book Two in the Cayman Islands Series), I wrote more detail about those injuries and recovery since that information fit with the characterization in one of the story scenes toward the end.

Like Dr. Littleton, I’m a Tar Heels fan – my son is a pre-med student at UNC Chapel Hill, headed to medical school to become either a neurologist or a pediatric oncologist. In addition to my EMS career, I have firsthand experience and knowledge with brain damage via my son – he was born with cerebral palsy, hypermobile joints, and dextrocardia situs inversus totalis with kartagener syndrome.

Due to his health issues, he easily suffered multiple concussions in high school and now struggles with chronic concussion syndrome. While his brain is healing, he’s able to succeed as a pre-med student, but it’s rough. His neurologist’s prognosis is my son will fully recover soon. A patient of my son’s neurologist was in a coma for a month from head trauma from a car accident. For several years this patient dealt with chronic concussion syndrome due to brain damage. Now, she’s a physician and fully recovered.
       

Unless I explicitly know something as a fact, I would never post it on the Internet (especially against another person) for the world to read. Just a friendly suggestion.   

Here is the link to the page of reviews of The Hidden Son on Amazon.

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Dianna T. Benson is the award-winning and international bestselling author of The Hidden Son and Final Trimester. Persephone’s Fugitive is her third release. An EMT and a HazMat and FEMA Operative since 2005, Dianna authentically implements her medical and rescue experience and knowledge into all her suspense novels. She lives in North Carolina with her husband and their three children. www.diannatbenson.com

Mysteries of Laura: Giving Insulin

The NBC detective show Mysteries of Laura might need a new medical consultant. In one of the first episodes of this season we have a boy that's been kidnapped and of course-- he's a diabetic in need of insulin or he'll die in short order.

Cut to scenes of distraught parents wringing their hands wondering if the police will get there in time to administer the life-saving medication.

Of course, when they find the young boy, he is unresponsive. One quick insulin shot into his leg and within mere seconds-- he's awake and crying.

This doesn't happen in real life.

The first thing to understand about why the medical approach to this scenario is bad is to understand why a diabetic who doesn't have their insulin gets sick. In a Type I diabetic, their body doesn't produce insulin. Insulin is what moves sugar from your bloodstream to the inner part of your cells for energy so they can function. When there is a lack of insulin, the sugar can't move from the outside to the inside of the cells and that's not a good set-up for sustaining life.

As a rescue measure, the body begins to metabolize fat and muscle for energy. The byproduct of this type of metabolism leads to a build up of acids in the blood called ketones. You can also get a build up of ketones in the blood from not eating carbs as well. When you do this, even though you may produce insulin, your body still perceives a starvation state and will enter into the same process.

In the case of the diabetic, the sugar is "stuck" in the bloodstream which is why they have high blood glucose levels. However, the reason a diabetic is so sick is not really from the high blood sugar-- it is really from the build up of acid in the blood from the break down of fat and muscle. This is also known as diabetic ketoacidosis or DKA. The more acidic a diabetic's blood is when they seek medical treatment-- the more emergent the condition.

So, in this episode we can assume that the diabetic is in DKA. The question is how long does it take to reverse this process?

In a nutshell-- hours-- not minutes. If a diabetic comes in unconscious then it will take them some time to regain consciousness after treatment is instituted to lower the acid levels in the blood and of course, by also lowering blood glucose levels.

What would have been a realistic medical scenario for this episode would be for the boy to have trouble with hypoglycemia or low blood sugar. Or, to have it be that the criminals were giving insulin but giving too much of it.

When a patient's blood sugar is too low, we give glucose IV. In this instance, an unconscious patient WILL wake up very quickly because glucose (sugar) given IV becomes immediately available to the cells for processing and a patient can and will wake up very quickly.

You can still be dramatic using an accurate medical scenario.

Injury by Arrow

Jocelyn Asks:

I’m now writing a book set in French colonial New Orleans, the years 1720-1722, and we’ve got some drama with the natives.

My MC gets hit with an arrow from someone who isn’t a very good marksman. Can I have him get the arrow in his chest without killing him? Like, if the angle is wrong, or if it wasn’t going super fast? I want the heroine to cut the arrowhead out of his chest, but I also want him to live. If he does survive, how long until he can get up and walk around?

Finally, I want to give him another scar from a previous arrow. Would he have survived an arrow passing through his side, by his waist? Or should I have an arrow skim across his ribs without penetrating? That would leave a scar, right?

Jordyn Says:

You can have an arrow hit a person’s chest without it killing them. It would all depend on where and how deep the arrow hit the individual. The faster the speed the more deeply the object will penetrate tissue. For instance, if I tap you with a bullet clenched between my fingers versus firing it from a gun—much different injuries.

The deeper an arrow is embedded in the chest, particularly the upper chest (where all the great vessels are) the more likely you are to do major, unsurvivable damage considering your era. To answer this question more fully, I’d want to know the size of the arrow. How long and wide is it? I would think anything measuring an inch or more would be worrisome for nicking something important like a large blood vessel or the lung. The way around this might be to have the person be fairly overweight and the arrow gets embedded into fat tissue. This might not be a good option for your hero.

As with all things—the person could just be lucky and the arrow hits but misses all vital structures. I would show this in your text by the character not bleeding heavily or having any difficulty breathing. That would allude to the fact that nothing major has been hit.

If it is merely a “flesh wound” and the arrow comes out in a fairly uncomplicated manner and no infection sets in then the character should have some mild to moderate muscle pain and soreness and perhaps some inhibited movement based on this but should be able to walk fairly immediately.

Someone can survive an arrow passing through the side of their waist, again, if it doesn’t hit any major organ. You have very vascular organs in your abdomen. The liver that sits under the right ribs and the spleen that sits under the left ribs. So, the lower the injury the better. Then you would just need to worry about perforating the intestines which would ultimately lead to sepsis and death but your intestines are housed under the fat layer and other tissues so could be fairly easily avoided. Any injury that requires stitches to approximate (get the edges close together) the wound will leave a scar so even a skimming injury that splits the skin will leave evidence of injury.

Use of Animal Tranquilizer Guns in Humans

David Asks:

In my new work in progress I have a woman shot with a tranquilizer gun. She is a former head ER nurse and is on the road. She has a well stocked medical kit. What would she have that could be injected to counteract the tranquilizer? Is there a particular tranquilizer they would use on her? They want her alive.

Jordyn Says:

Thanks so much for sending me your question.

This is an interesting question that you ask. The first part that should be answered is what kinds of drugs are generally used in animal tranquilizer guns. I was fairly surprised to see some of the same drugs we use in humans like opiates (Morphine and Fentanyl.) Interestingly, it looks from this article that the opioid compound used is called M99 which is 10,000 times more potent than morphine and one drop is lethal to humans. It is reversible with a drug called Narcan or naloxone.

A second class of drugs that is used in humans also used in animal tranquilizer guns are the benzodiazepines. For humans these would be drugs like valium, ativan and versed. There is a reversal agent for this class of drugs as well. We call it flumazenil.

Two other drugs were listed in the article. Another drug that we use in humans was a substance that is related to ketamine but does not have a reversal agent. The last, azaperone, which is not familiar to me as a drug used in humans and is also not reversible.

If your ER nurse had a well stocked medical kit then she would have the drug naloxone on hand to reverse an opiate drug if that was used in the tranquilizer dart. What's both interesting and sad about naloxone is that it is becoming readily available to the public because of the drug problem in the USA. So, even if your ER nurse didn't have a well stocked medical kit she could probably find some as long as the dart didn't immediately kill the victim. Opiates cause death by inhibiting your respiratory drive. You simply stop breathing. There are certainly other effects but this is the primary one.

The other drug, flumazenil, that reverses benzodiazepines isn't as readily available so that might not be a great choice for your story.

It's also important to note that from the article, just as in humans, a combination of drugs might be used. So, naloxone might reverse the opiate but not whatever else is in the syringe. Also, animal darts are likely loaded with more medication that would be more likely to produce toxic and dangerous effects to a human than say a bear.

I hope this answers your question and good luck with your novel!

How Would You Fake Lab Results?

I feel like I'm going to owe an apology to How to Get Away with Murder as this will be the second time I've called them out in the last couple of months for medical inaccuracies-- or let's just say my personal issues with some of the medical stuff they're floating out there.

You can see my first issue here.

One of the male characters in How to Get Away with Murder, Nate, has a wife who is terminally ill with cancer and wants help committing suicide. She first approaches Annalise Keating, the lead character and attorney to help her get her hands on some pills that will do the trick. And why wouldn't Annalise? She is after all sleeping with her husband.

Over the course of a couple episodes, Annalise does get her hand on some pills, actually gives them to the husband who then gives them to his wife who does commit suicide. Actually, it is a little unclear to me who gives her the pills but the husband is accused of murdering his ill wife.

Unfortunately for Nate, there's a district attorney who's been gunning for him and would like nothing more than to see him in jail. So, even though the wife has been cremated, there's some residual blood left over that she wants tested for the presence of this drug.

Nate approaches a sympathetic hospice nurse to switch out the blood samples so the drug doesn't show up.

Well, probably not very realistic and I'll tell you why.

Keep in mind the whole set up for this trade out is that the blood is already in the lab and the patient is deceased. This part of the scenario is actually plausible. Labs do hang onto specimens after patient's die for a number of reasons.

The first thing to know about labs is it's the one place nurses do not go. I've never been inside a lab-- except on a tour. There's generally a door where you can drop off specimens but you're generally not permitted to enter. So, how does this nurse gain access to the specimen to switch it out?

One, it's going to be odd for a nurse to be snooping around the lab. I mean, notably odd. That's something a lab tech is going to remember.

The other issue is the labeling of the specimen. Even if the nurse gained access to the lab, found the specimen, and was going to replace it (say with her own blood)-- she would need a new label back dated to the time of the "real" specimen. You can hand write out labels but this is very rarely done and I think would raise suspicion as well.

So, the only great way to switch out blood to keep the drug tainted blood from the lab is to do it at the time of collection. Someone draws blood from another person that they know has "clean" blood and puts the patient's label on it. Unfortunately, this isn't a possibility because the patient has died.

There is a way to work this scenario to have it be more realistic-- I just don't think this is the best way.