Tuesday, December 30, 2014

Fun Video Blog Break: Tim Hawkins on Breaking Mom

I LOVE comedian Tim Hawkins. Enjoy his discussing the importance of giving moms a break.

Thursday, December 25, 2014

Video Blog Break: Imperfect Perfection

What is the value of a life? This dad teaches us a lot about it.

Sometimes our ideas of perfection get turned upside down. But if we can focus on what God might be teaching us, we can come away with a much fuller life filled with imperfection.

Merry Christmas.

Tuesday, December 23, 2014

Fun Video Blog Break: Stayin' Alive

One of my favorite videos from this year was Chattanooga Firefighters using some creative teaching in how to do proper CPR.

Great work, guys. I always love a medical lesson taught in an inventive way.

Thursday, December 18, 2014

Fun Video Blog Break: Tim Hawkins

My favorite comedian is Tim Hawkins. There're tons of videos of him on You Tube. If you need a good laugh, check out his other videos.

Tuesday, December 16, 2014

Fun Video Blog Break: Jimmy Fallon Hashtags "WorstGiftEver"

Starting off our funny blog break is Jimmy Fallon. If you're not watching the show, he does a weekly hastag. This one is #WortstGiftEver.

What was your worst Christmas gift ever?

Thursday, December 11, 2014

Author Beware: Medical Students

I've blogged here a lot about the trouble many authors have with scope of practice issues. Scope of practice is what the licensing board says you can and can't do to a patient. Every licensed healthcare professional has a defined scope of practice. For nurses, it is managed by their State Board of Nursing. For doctors, it is the Board of Healing Arts.

You can find other posts I did about scope of practice herehere and here.

I recently came across a novel written by a doctor that had an interesting medical scenario. In short, a medical student was running amok killing patients by overdosing them on potassium. Below are a few highlighted portions from the novel. I'm using asterisks instead of characters names to further disguise the story to protect the author.

This portion is written from the medical student's (the killer's) POV:

I was helping them (nurses) with their work. I've fixed IV pumps, drawn blood, placed catheters, even changed bedpans. It's got me into their good graces, and a lot of them now pretty much trust me with anything. Like giving medications. 

They'd pull the IV bag from the electronic medication dispenser, log it into the system, hand it to me, and go back to doing the twenty other things they were trying to do at the same time. They never gave me or my poor little bag of potassium a second thought. 

And why not? They'd seen me give IV medications to patients hundreds of times. Not one of the-- not a single one-- even bothered to check to see if the patient actually needed potassium, much less confirm that I'd actually given it."

Honestly, it's hard to know where to start with the medical inaccuracies this small piece of fiction highlights.

1. A medical student is not licensed healthcare provider. Therefore, they practice under someone else's license. They are managed by their attending physician or resident. They are not monitored by nursing. A nurse is not going to let a medical student do these things to her patient. The most a medical student does is obtain a patient history, do a physical exam, and observe procedures by other physicians. If this author had made the medical student a resident-- the scenario would be a little more plausible.

2. Every nurse is not that stupid. Sure, one nurse allowing a medical student to give her potassium I could believe. But, as in the novel, up to fifty? Remember, the nurse is likely more liable than the medical student under this circumstance. These nurses would all be fired. Nurses are not that blase about their licenses. Without one, even a license with a minor mark, and that nurse will not be working in nursing ever again. Medical students are learning. A nurse's job is to protect her patient. We don't trust medical students to be competent in what they're doing for that reason alone.

3. The author also misses another layer of protection. Medical dispensing machines are another layer of protection. Hospital medications are approved for dispensing by the hospital pharmacist. So, a pharmacist can look up a patient's lab results and check whether or not they need the potassium as well. All these medication orders on patients that don't need potassium is going to raise some serious alarms. Can you override the medication dispensing system? Yes, but you better have a good reason. Many hospitals have removed concentrated forms of IV potassium because an error could be so potentially deadly to the patient. Also, patients who receive a bolus dose of IV potassium need to be placed on an ECG tracing (or continuous heart monitoring.) In this instance, they are generally in the ICU or on telemetry and not a basic med/surg unit.

The scenario could be plausible if written another way. Overall, the author needed a seasoned ICU nurse to review the manuscript.

Tuesday, December 9, 2014

Author Beware: Use of Electricity

Authors, television producers and scriptwriters are fascinated by the use of electricity. This is probably one of the most commonly abused medical scenarios in that it is rarely used correctly.

One of my most popular posts here at Redwood's was a post titled Shock Me To Death that highlights how electricity (or defibrillation) should be used.

I was reading a debut novel by a medical doctor and found many grievous errors around the use of electricity. Which distresses me because he also said he had a cardiologist review the manuscript. Seriously, I kind of want to know who that doctor is and what kind of training he had.

There was the usual error of shocking a flatlined patient or asystole. Remember, in order for electricity to work, there has to be some present. If a patient is flatlined, there is no disorganized cardiac rhythm to reset and so defibrillation is contraindicated in those patient scenarios.

Next error in this manuscript was cracking the sternum down the middle during compressions. For one, the sternum is extremely hard to fracture. It's designed to protect some very important organs. If the sternum is even slightly fractured, we know there have been extreme forces placed on that patient. So, to have mere hands fracture a sternum all the way down the middle is ludicrous. Remember, they saw this open for open heart surgery. Breaking ribs is very probably during CPR, but not the whole length of your sternum . . . sorry.

Last, and most creatively (as I'd never seen this error before), was the amount of electricity used in an ICD device (an implanted cardiac defibrillator.) ICD's are devices that are used to convert patients from lethal arrhythmias like v-fib and v-tach. They are not pacemakers-- which stimulate the heart to beat.

Whenever electrodes are placed near the heart, the amount of electricity used is very small. Think about it. When we shock you from the outside of your body, the electrical current has a lot of tissue to pass through to get to your heart. This is why we use more. When defebrillating someone-- it's in joules.

A pacemaker uses a lot less energy. Outside pacemaker use milliamps.

And here is the very interesting quote from a published novel:

"Cardiologists shock patients all the time under controlled conditions, remotely dumping up to 700V (volts) of juice directly in to the heart via the ICD."

Wow. That's just . . . overkill.

Just how lethal is 700 volts applied directly to the heart?

This site explains that 110V can kill you.

It's so egregious an error that I'm not quite sure what this author was thinking. It pains me more that he is an actual medical doctor. I even double checked the published manuscript (as I'd read a galley proof before) and the error was still present.

I think he needs a new cardiologist.

Sunday, December 7, 2014

Up and Coming

Hello Redwood's Fans!

Are you enjoying the Christmas Season? How's the holiday shopping going?

I am excited to say that I am nearly done-- I'd give it a good 90% completion. I think this is going to be my goal in subsequent years. Shopping done in November. Presents wrapped by early December and then just enjoying the season.

For you this week!

An Author Beware series. These posts focus on what an author has done horribly wrong in a published novel. I never mention the book or the author (unless they are making millions and I know they can afford to hire me for medical consulting.)

This series focuses on two very common errors but this author used them in more egregious ways-- the use of electricity and scope of practice issues.

After that will be my annual blog break but I hope you'll tune in for the funny videos I share every year.

I hope each of you has a wonderful Christmas and exciting New Year. I'll be back to the medical mayhem on January 6th.

Much Love and Merry Christmas,


Thursday, December 4, 2014

Author Question: X-ray Anomalies

Barry Asks:

I have a character who is getting X-rays for headaches and vision problems. The X- rays show some kind of anomaly on or near the brain which requires a CT scan for further investigation. The CT scan needs to show something. I said a shadow, but any anomaly would work which cannot be biopsied due to the location.

For the development of the plot I need the doctors not to be able to ascertain immediately if the object on the scan is malignant or benign. Could this scenario work and would doctors wait to see what develops, or is there another course of action they would suggest in the absence of a biopsy?

Jordyn Says:

Very interesting question, Barry.

First of all, you're starting off with the wrong test. An x-ray (or plain film) is done merely to look at bones and is not the test indicated for your character's condition. A skull series would merely show fracture or bony tumors. It doesn't show brain tissue. Its primary indication is skull trauma-- looking for certain types of fractures that might indicate the need for neurosurgical evaluation. 

What your character really needs, ultimately, is an MRI. This might solve both of your problems. The concern for a patient with headaches and vision problems is that they could have a brain tumor. An MRI has the ability, in some cases, to distinguish between malignant and benign tumors. So, if the tumor location is in an inoperable area, such as the pineal gland or corpus callosum, then you could build your scenario around this.

If, as the author, you want to have a wait and see period, then your option would be to have the tumor not be differentiated on MRI but small in size. Then, the doctors could do serial MRI's every 3-6 months to see if the anomaly changes. 

However, the likely initial radiologic study of choice in the ER setting for your character's symptoms would be a CT scan of the head. The reason for this is that CT scans are very quick (less than five minutes.) An MRI of the brain can take anywhere from 30-60 minutes and are more expensive. What will show on CT is something bright white. Tumors and blood show up bright white on CT scan. Then, follow-up for the patient would likely be neurosurgical evaluation with an MRI scan. 

The term "shadow" is more reserved for ultrasound studies according to the doctor I spoke with. So I would adjust your terminology in that aspect.

Best of luck with your novel! 

Tuesday, December 2, 2014

What the Difference Between NICU and PICU?

Within the last several months, I was having a conversation with a reviewer and he interchanged the words NICU and PICU several times and it became clear to me that he didn't really understand the difference between these two units so I thought I would clarify that here today.

A NICU, aka Neonatal Intensive Care Unit, is specifically for babies who have just been born and are having difficulties. This includes premature babies (23-24 weeks is considered viable) up to normal gestational age of 40 weeks. This is their area of specialty.

The problem becomes-- when can the babies go back to the NICU if they become sick? Often times, a NICU won't take a premature baby back once they've been discharged home for a couple of months (even if they are still an infant) because they could be "contaminated" with all sorts of other-worldly germs. So, if the infant is sick enough and needs an ICU admission they will likely (though not always) be admitted to the PICU.

The PICU, aka Pediatric Intensive Care Unit, is for infants the NICU won't take and all other kids up to about the age of 18 (some up to 21) or whatever age the pediatric hospital has decided to admit. Even this age cut-off is becoming blurred because patients with chronic diseases (cystic fibrosis or special needs kids) might stick with their children's hospital well into their 20's. This is becoming an area of concern for pediatric institutions-- how to transition adults into adult-centered care.

Another way an adult might end up in the Pediatric ICU is if they have had a repaired congenital heart defect. There really is a limited number of adult cardiac surgeons who are comfortable operating on adults with these defects. In all honestly, it's only been in the last couple of decades that these kids were living to adulthood but improved surgical techniques have changed all of that.