Editor's Question: Consent for Rape Kit in Unconscious Victim

During my blog tour for Proof I had an interesting question from fiction editor, Ramona Richards, in the comments section of the blog on this post that dealt with collecting a rape kit.

Ramona: If a sexual assault victim is stable but unconscious-- will the medical team do a rape kit and if so-- who do they get consent from?

Jordyn: This is an interesting question on many levels. As a nurse, I'm first an advocate for the patient but also as a nurse and woman-- I want to see justice happen for this woman as a victim.

The central issue is that part of the rape kit is very invasive. Particularly the pulling of the hair from the head and groin area and well as the internal pelvic exam.

No one wants to put a victim through something more traumatizing-- so generally-- permission must be given by the victim in order for the exam to be done.

But say-- the victim looks like she is not going to wake up to give that permission?

Part of the exam can be done. External evidence and swabs can be collected. An external exam of the vaginal area could also be done. Pictures can be taken.

Likely-- we'll wait to see if the patient wakes up. Nothing should be disturbing the internal presence of the evidence if the patient is hospitalized. Exams should be done within 72 hours and one nurse practitioner I work with said semen could be preserved on the cervix for 10 days.

But what if it looks like the victim is never going to wake up?

Then it becomes an issue for the courts. They would have to issue an order for the exam to be done. So either the victim has to give permission (and no-- not next of kin)-- or the court would order the exam to be done.

Author Beware: Delusional Diagnosis (2/2)

Last post, I discussed the issue of heart palpitations and how, in isolation, they can be benign and not representative of heart disease.

The line in this particular published novel that did get my ire up is shortened as follows: "Any experience terrifying enough to cause a panic attack, in extreme circumstances, causes an arrhythmia. That's a heart attack."

Really? No. There's a lot medically wrong with this sentence.

First, in very general terms, a heart attack is caused from lack of oxygen to the heart muscle, generally from a clot in an artery that feeds blood to the heart-- your coronary arteries. When the heart muscle is not getting oxygen, it becomes irritable. One interesting thing about your heart is that each cell can generate an electrical current that will contract heart muscle. It generally does not do this due to the over-riding normal pacemaker. However, when oxygen is cut-off and the heart cells become irritable, they can begin to fire outside the normal conduction system.

When this happens, the medical team begins to see aberrant beats. But see, the heart attack itself generally causes the arrhythmia, not the other way around.

Let's stay on track with this character. A healthy, college age woman. The incidence of actual heart disease is going to be low. What causes chest pain during a panic attack? Generally, the heart rate may be faster than usual. However, the truly rapid heart beat of SVT (more on that later) I would say is rare and would point away from the mind and more to the conduction system in the heart.

The last thing to consider is that people who have true heart arrhythmias, may have structurally fine hearts. Meaning the muscle, valves, and coronary arteries are good. Just the conduction system is a little funky.

My advice for authors-- don't make blanket medical statements. Just like they taught you in school-- sentences that have all, every, etc... are likely the wrong answer.

Author Beware: Delusional Diagnosis (1/2)

There's nothing I hate more as a reader than to be happily reading along a novel that I really like and come across a medical issue that begins to pull me out of my snow globe of a story bubble. It's even worse when it begins to keep me up at night and I dream up a whole blog series about this issue.

That means things are really bad.

This happened recently. The story is actually quite good. Solid, interesting premise. Had it not been for this medical issue that was a thread through the entire story, I'd easily give it a five star rating. But, because of this medical issue and how it was painted, I downgraded my review just for that reason.

It made me wonder if the author had talked to someone in the medical field. And if they did, who it was. I mean, the 125 year-old retired dermatologist may not be the best resource. For dermatology-- yes, absolutely. Otherwise, just sayin...

And I love dermatologists by the way. But if I'm dying-- please find me a cardiologist!

The issue surrounded palpitations. The author began to write about how the lead character was having palpitations and how she was concerned this represented a major heart issue that would ultimately lead to her not being able to pursue her ultimate career goal. The author painted it as a major event in her life.

I'm going to ease off a little here as patients are often this way. They worry that a minor symptom represents a major life-ending disease. Happily, this if often not the case. So, it's okay to do that... in the beginning. I'll cover the major down side of this book next post.

Let's cover what we know. What are palpitations?

Palpitations are merely the sensation of your being aware of your heart beating. Normally, you can't feel that muscular pump busily working in your chest. Is doesn't keep you up at night with its never-ceasing beating nature.

Palpitations are often skipped beats. When your heart skips a beat, sometimes blood doesn't flow out as it naturally would and this fullness can be felt. Normally, these skipped beats aren't anything too concerning if they happen every so often. More worrisome is if it is happening all the time and/or associated with chest pain and/or shortness of breath.

Palpitations can also represent rapid heart beats or irregular heart beats. These can be a little more worrisome.

However, some people with palpitations do not have heart disease or an arrhythmia. This character happened to be a young, healthy college student which makes these diagnosis more unlikely.

Come back for Part Two of Delusional Diagnosis next time.

Author Question: Refusing Medical Treatment

Carrie Asks:

My novel is set in the US and my MC, who's eighteen, is injured. He's suffering from concussion, blood loss, and hypothermia, and is very weak and quite disorientated. He is, however, conscious and responding, and adamant that he does not want to be treated or taken to a hospital (and the plot requires him not to be). I understand that he'd be able to refuse treatment if he signed a form saying so. My question is, is there a standard procedure that an EMT would follow before letting him sign?

Jordyn Says: Thanks for e-mailing me your question. You have an interesting scenario here.

I'm going to come from the standpoint of this person presenting to the ER. Put simply, we are not going to let this patient sign out AMA. A couple of things in your statement about his condition will prevent this. Almost everything you've listed as far as his medical condition makes it impossible for him to make a reasonable decision regarding his care--concussion, disorientation, hypothermia. Even though he can talk, it doesn't mean he has enough medical capacity to make an appropriate decision regarding his care until these issues are straightened out.

We would do everything in our power to keep him in the ED. Considering that-- you have a couple of options. Make him a lot less sick. Maybe just a few bumps and scrapes. Or, he could elope from the ED somehow, but if we were really concerned about his medical condition we might send the police to fetch him back. Of course, this could add conflict into your story.

I did verify this through an EMS friend of mine as well. The issue is not whether or not they can talk, it's whether or not they are medically competent to make a decision about refusing care. This character's condition precludes that.

Author Beware: Unsecured Narcotics

I was happily reading along one of my favorite best-selling authors when I stumbled upon a troubling set-up. Now, this author makes a lot of money which is why I'm not sure the reason for his not picking up the phone to consult me on his manuscript.

One character had been beaten up fairly well. He was in the hospital on a Valium drip. Huh? That's right, just a bag of Valium hanging and dripping into his veins.

Issue One: Valium is not a pain medication per se. It is a muscle relaxant which can relieve pain from a muscle spasm. However, if you have had the snot beat out of you, let me introduce you to my friends the opiates: Morphine, Fentanyl, etc. These are likely what we would give first for pain.

Issue Two: Valium is not given in a bag as a drip. In fact, I can think of few instances where Valium would be given as a continuous medication. Some shorter acting friends of Valium are-- but you generally have to be in the ICU on a ventilator to get some. This character was not.

Issue Three: Narcotics need to be secure. If a patient needs a continuous amount-- this is what PCA (patient-controlled analgesia) pumps were made for. They are locked IV pumps so that no one can steal the drug from the bag and so that the patient cannot manipulate how much they receive.

Pediatric ICU's do run a lot of continuous drips that are not locked. In these instances, usually a calculation is made at the end of a shift to look at the amount remaining. If the syringe is off by more or less one millimeter-- then generally an incident report is filled out.

So bestselling, multi-million dollar author--- really, just call me up. I'd be happy to help.

Have you read a scene with inappropriate use of narcotics?

Author Beware: Hallmark's Christmas Magic

There's nothing more charming for me than a Hallmark Christmas movie. Several I loved this past Christmas season-- particularly Trading Christmas written by Debbie Macomber. Hilarious if you're a writer.

Some I didn't like as much-- and you guessed it-- had to do with a medical reason.

Christmas Magic was a Hallmark movie where a young PR exec was involved in serious car accident.

Spoiler alert!

Most of the movie, you're led to believe that she has died and is doing some angel work before going to heaven. At the end of the movie-- you learn she has been in a comatose state and the climatic scene is where the man and daughter she was trying to help, come to her side at the hospital, to sing her back to life before her father "pulls the plug."

My first issue: You should actually look injured if you've been in such a devastating car accident that you've been lying in a hospital bed for the better part of a week. In her "death" scene, her hair is clean and styled. Nary a scratch on her pretty face. Exactly what was her injury? Supposedly brain trauma. Well, she should at least have a bruise on her head.

My second issue: Pulling the plug generally denotes that you are on a ventilator. Discontinuing the ventilator-- pulling the plug-- means a patient's breathing is no longer being assisted, they then cannot oxygenate their body, and the heart will stop beating when it doesn't have oxygen.

In this scene, she was on a heart monitor (which is merely a monitoring device) and an IV bag of fluids hung at her bedside. She was not on a ventilator. Therefore, no "plug to pull".

To denote discontinuing "life support" the nurse in the movie turned off the IV solution where then the heart began to slow down. Okay, you will die if you are in a comatose state from dehydration (think Terri Shiavo's case) but it will not happen in a few minutes. It will take days.

But, this patient was able to comply and nearly died in a few short minutes.

Next season, Hallmark Channel, hire me as a consultant. You might be surprised at how inexpensive I am!

How to Write a Hospital Scene: Amitha Knight

As a doctor, I don’t like reading books or TV shows about doctors. Not because I’m jaded and think I’ve heard it all before (quite the contrary) but because often, it feels like the writers just haven’t done their research. I’m not talking about highly involved medical research—it’s the basics that can trip you up.

Here are a few questions to think about when writing a character’s hospital scene (please note that some of this is for US hospitals only).

1. Is your character on the right floor?

As many people know, hospitals are set up with different patients in different areas of the hospital. There are pediatric floors, adult floors, surgical floors, maternity floors, ICU’s, etc. Knowing where your character/patient would be placed in the hospital depends a lot on the type of hospital you’ve chosen for your story. Is it a small community hospital in a small town? Or a large teaching hospital in a major metropolitan area? The smaller the hospital, the fewer wards there will be (and often the really serious cases would quickly be sent over by ambulance to a bigger hospital). In larger hospitals, the ward will be more specialized so you shouldn’t expect to see mixing of patient types (i.e., adult surgery patients in a medical ICU ward).

Why does this matter? It has to do with your setting details. For example: If your character is in the ICU, he/she won’t see a lot of patients walking around with IV poles in their hands. And the rooms in maternity ward have more privacy than in an ICU setting. If your character is the doctor rather than the patient—they won’t be wandering around random hospital wards. Your medical intern isn’t going to be regularly wandering around the pediatric wards and playing with kids there.

2. Who will be taking care of your character/patient?

This can be confusing and again, depends a lot on the type of hospital in your story. Let’s say you choose a teaching hospital. Who will be taking care of your character? I’m going to focus on the different types of doctors and doctors-in-training because that’s what I know the most about.

Medical students: These are students in medical school. They have not yet yearned their MDs so they are not “doctors”. Medical students are often allowed to see the patient first and ask questions—but not in an emergency situation. They do not make medical decisions for your patients.

Residents and Interns: These people have graduated from medical school and thus are “doctors”. They see their own patients and make some medical decisions, but are still in training and run major decisions by an attending physician (see below). Interns are what residents are called when they are in their first year of residency. In some specialties, residents have to do a separate intern year at a different program before beginning their specialty training. That’s why the distinction is made.

Fellows: These are people who have finished their residency but are doing further specialization and are also overseen by an attending physician, though less closely than a resident.

Attending Physicians: An “attending” is the doctor who is ultimately in charge of your patient during their hospital stay. All major decisions will have to be run by him or her.

This hierarchy can make a huge difference to the believability of your story. For example—a medical student or an intern will not be in charge of breaking bad news to a patient unless they have forged some strong bond with your patient. This is generally the role of the attending physician. Likewise, the attending physician will not be doing “scut work” (tedious hospital work, ordering tests) unless they are in a hospital where they don’t have interns and residents around.

3. Which patient will your doctor characters see?

This is one of the reasons I can’t watch Grey’s Anatomy. If you are a surgery resident, you will not be delivering babies. If you wanted to do that, you would have done ob/gyn. If you are an ob/gyn resident, you will not be taking care of babies in the neonatal ICU. If you wanted to that, you would have done pediatrics. And if you are a pediatric resident, you will not be doing surgeries. Please, get it right! Your doctor characters really can’t do it all!

Originally posted to the Guide to Literary Agents Blog. Reposted with author permission.

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 Amitha Knight is a former pediatric resident turned writer of middle grade and young adult fiction. She’s also a blogger, a book lover, an identical twin, and a mom. Follow her on twitter @amithaknight or check out her website: http://www.amithaknight.com/.

C.J. Lyons Interview: Part 2/2

Today, I'm concluding my two-part interview with New York Time's bestselling author C.J. Lyons. If you're a fan of medical thrillers and haven't read C.J.'s books, now is the time to start. The focus of today's questions is on aspects of the writing craft.

Jordyn:  After reading through several of your past interviews, I discovered we’re really kindred spirits. I, too, started writing at a very young age. Do you still have these stories? Have you adapted any of them into your current novels?

CJ: LOL! No, they'll never see the light of day. My stories when I was young usually involved a girl and her horse off fighting some form of injustice in history (I was fascinated by history as a kid, so my stories were set in the Wild West or Civil War or American Revolution).

Jordyn:  I think you’re one author who has successfully navigated both traditional and e-book publishing. What would you say are the best three ways to market a novel?

CJ:  Know your reader, know your story, know your strengths. Write a story your reader will love and use your strengths to connect with them and let them know it's out there. Really, it's that simple. Marketing is making a promise to your readers and keeping it. How you do that depends on where your strengths lie.

Jordyn:  Your novels are character driven. What are some strategies you use to develop imperfect heroes and sympathetic villains?

CJ:  It all starts with my character's default action at the start of the story. What they think is their greatest strength on page one, I slowly make their greatest weakness by the end of the story until they sacrifice that old default action and learn a new one. Villains are on their own hero's journey (no one wakes up one day deciding to be the bad guy, we all think we're heroes of our own lives) so I do the same with them, only in the end they don't make that sacrifice and learn from their mistakes, allowing the hero to defeat them.

Jordyn:  I was sad to learn of the tragic murder of a friend of yours during your residency. How did writing serve to help manage the chaos in your life during that time?

CJ:  After Jeff's death I wrote my first crime fiction story, Borrowed Time. I think I needed to switch from the SF/F I had been writing before then because suddenly I needed to know that justice could be served and that good guys could win, despite the forces rallied against them. I've been writing thrillers ever since.

Jordyn:  What was it like co-authoring a novel with Erin Brockovich? How did you divvy up the writing?   

CJ:  Erin and I have never actually met in person—her travel and work schedule is crazy! We spoke on the phone and via email. It was so amazing to work with a personal hero of mine and I love it that we were able to create a character that embodies the philosophy that both she and I share: that heroes are born everyday.

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As a pediatric ER doctor, New York Times Bestseller CJ Lyons has lived the life she writes about in her cutting edge Thrillers with Heart.  

CJ has been called a "master within the genre" (Pittsburgh Magazine) and her work has been praised as "breathtakingly fast-paced" and "riveting" (Publishers Weekly) with "characters with beating hearts and three dimensions" (Newsday).

Learn more about CJ's Thrillers with Heart at http://www.cjlyons.net/

CJ Lyons Interview: Part 1/2

I'm honored to have had the chance to interview CJ Lyons, past pediatric ER doctor and now full-time author extraordinaire. If you haven't checked out CJ's books, now is time time, particularly if you're a fan of medical thrillers.

Today we're going to focus on aspects of medicine in writing. On Wednesday, we'll focus just on the writing craft.

Jordyn:  Thanks so much for stopping by. It’s my great honor to have you here. Redwood’s Medical Edge is all about dispelling medical myth. Along those lines, what do you see as the most common medical mistakes perpetuated in fiction writing?

CJ:  The most common (and irritating) mistakes I see deal with the characters. For instance, the popular TV show Grey's Anatomy has interns, who'd be maybe 25 years old, sleeping with "world renown" surgical attendings…well, to be a "world renown" neurosurgeon you'd have to have 12 years of primary education, 4 years of college, 4 years of medical school, 7 years of residency, probably another 3 year fellowship, and then be in practice a long time, at least 5-10 years…so the 25 year old intern's love interest would be old enough to be her father! Gross!

Not only that, a surgical intern doesn't have time to sleep or bathe (interns eat on the run) so sex isn't the first thing you think of doing when you finally do make it to a call room.

Don't even get me started on stories where a "doctor" can do everything from take x-rays (99.9% of us wouldn't even know where the "on" button is) to diagnose rare diseases from glancing into a microscope to doing brain surgery one minute and heart surgery the next…while I love the idea of doctors being heroes, let's at least make us human.

Oh, and I've only met two physicians who drove Porsches, both orthopedic surgeons, freshly divorced and shopping for new wives. At the community pediatric practice where I worked, the guys who plowed the snow were paid more than we were. So just because a character is a doctor doesn't mean they're rich.

Jordyn:  What about the most common medical myths?

CJ:  Those magical "blacked out" incidents. Where the character is hit on the head and wakes eight hours later in perfect condition, ready to chase after the bad guys…or the Taser hit that instead of lasting the five seconds it does in real life, knocks someone out for a prolonged time.

Sorry. In real life, your guy with the head injury would probably be dead or dying of a brain bleed and people who are Tasered don't black out at all (although they might wish they did)—in fact some of them stay perfectly functional while being Tased, much to police officers' dismay.

Jordyn:  I read with interest that you had worked with a community group of pediatricians that served an Amish community. Amish books are selling briskly on the inspirational market. Do the Amish have any medical beliefs that differ from western medicine? What are some of the unique aspects of working within the Amish community as a doctor?

CJ:  We had a variety of patients when I was working at a community pediatric practice in Pennsylvania, including Amish. But also Chinese, Russian, Pakistani, Turkish….and every demographic from the very poor to millionaires who kept their family home in our idyllic mountain setting and flew their privates jets to and from their offices in DC or NYC every week. It was a great experience, because like the ER, you learned very quickly not to judge anyone because of their appearance or accent or attitude.

Jordyn:  You spoke once about how you had a fascination with ghost stories. Speaking as a physician, do you have any thoughts on near-death experiences and what they might mean?

CJ:  I think there's more going on in the universe than we understand or can imagine. It's hubris to think we have all the answers—or ever will. As for near-death experiences, I actually used one in Borrowed Time to set things up for the main character. She's a cop, shot and killed in the line of duty on page 3, and brought back to life by a trauma surgeon. But she's now seeing things, visions of other people's deaths, and suddenly everything she once had faith in: her abilities as a cop, her trust in herself and her fellow officers, even her sanity is questioned.

Jordyn:  What are three things you’d like President Obama to know about the healthcare system after serving families for seventeen years as a physician.

CJ: Not just the president, but everyone. First, just because kids don't vote shouldn't mean that their health care is put last. It should be top priority along with education and feeding them. Without healthy kids energized to learn the skills they need to take us into the next century, we have no future.

Second, there is no universal formula doctors can follow. Yes, we need evidence based medicine to help us tailor our choices, but it can't be about cost, it has to be about effectiveness, about what's best for the patient in front of us here and now.

Third, from my point of view as a physician on the front lines, the HMOs already cut all the fat from the medical field and put that cash into their own pockets decades ago. The only place left to cut now is trimming the bureaucracy. Which would not only save money but improve health care quality because then doctors would have time to spend with patients instead of wasting it arguing with administrators.

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As a pediatric ER doctor, New York Times Bestseller CJ Lyons has lived the life she writes about in her cutting edge Thrillers with Heart.  

CJ has been called a "master within the genre" (Pittsburgh Magazine) and her work has been praised as "breathtakingly fast-paced" and "riveting" (Publishers Weekly) with "characters with beating hearts and three dimensions" (Newsday). You can find out more about C.J. by visiting her website: http://cjlyons.net/ 

Author Beware: The Law-- HIPAA (3/3)

Today, I'm concluding my three-part series on the HIPAA law. I'm going to focus on how I've seen it violated in published works of fiction.

Situation 1: A hard-nosed journalist makes entry into the hospital and begins asking the staff about a current patient. One nurse pulls him aside and gives him the information. This is a clear violation of HIPAA. All media requests will go through the public relations office. For any information to be released, the patient needs to give their permission.

Situation 2: A nurse on duty calls her friend and notifies her that another victim involved in a crime spree that her sister was a victim of is an inpatient at her hospital. Again, unless that person has provided direct care to the patient or the patient gives their consent for the information to be released, the nurse is in violation of HIPAA. However, the author of this particular ms handled it well. At least she had the character divulge that she could get in "big trouble" if upper management found out what she'd done. Think back to Brittney Spears in part one of this series.

Situation 3: Small town high school mascot falls ill on the field during a football game and is rushed to the hospital. A paramedic takes him to the ER. When the paramedic's wife arrives, she inquires about his condition. The paramedic/husband tells her what the doctors found. Again, the wife is not providing direct medical care to the patient. This paramedic has violated the patient's HIPAA rights by divulging this information to his spouse. Now, I understand, in small towns-- this information may "leak out". A better way for the author to have handled this would have been to have the wife of the fallen mascot tell this woman what his diagnosis was. HIPAA doesn't apply to family members and they can willingly share information with who they wish. That may not make the patient very happy--- ahh... another area of conflict!

Have you seen HIPAA violations in works of fiction that you've read?

Author Beware: The Law-- HIPAA (Part 2/3)

Situations involving minors can be an easy way to increase conflict in your manuscript. Here is an easy area to use.

Minors presenting to the ED for evaluation of a pregnancy or STD related complaint.

Here's a set-up. Mother brings her 14 y/o daughter in to "get checked for pregnancy". Okay, great. Already we have inherent conflict. After all, if the daughter was in agreement about allowing her mother to know this information, they could have done a home pregnancy test and matter solved.

At times, parents will bring their children to the ER thinking that, because they've signed them in as a patient and they're the parent, we'll have to do as they ask and they'll learn the information that way.

This isn't the case. Will we do the pregnancy test? Maybe. The patient has to be willing. Will we relay the pregnancy test results to the parent? If the 14 y/o patient says "no" then we will not.

Most states have laws surrounding minors that issues related to pregnancy or STD's is protected information and can only be released to the patient. Depending on the state, the cut-off is 13 or 14 years. This is different from us giving information about a follow-up culture for strep throat.

I've had parents call back for test results. I had a step-mother call for pregnancy test results on a patient. Nope, can't give you the information.

Another area is that minor patients can sign themselves into the ER without parental consent for these matters as well. Generally, for all other conditions, we have to make attempts to get the parent on the phone for verbal consent witnessed by two individuals.

What do we do?

As healthcare providers, we really do try and facilitate open dialogue between the parent and child. We'll sit with the 14 y/o daughter privately and go over why it would be best for her to share this information, regardless of the results, with an adult.

Can you think of other healthcare situations involving minors that could be high areas of conflict?

Author Beware: The Law-- HIPAA (Part 1/3)

Several months ago, I was watching a local TV news station when a nurse manager was being interviewed about the fact that you could look up ER wait times on the Internet before checking in. That's a whole other can of worms I won't get into today but the problem with her interview was that the camera shot included her standing next to their patient tracking board in which you could clearly see the last name of the patient, their age, and their medical complaint.

I almost fell out of my chair. This was a clear HIPAA violation and that ER manager should have known better than to be standing anywhere near that board.

Each time you visit the doctor's office or sign into the urgent care or emergency department for treatment, you should be given a paper that outlines your rights under HIPAA which stands for the Health Insurance Portability and Accountability Act. It basically outlines rules on how to deal with a patient's "protected health information" or PHI.

What this boils down to for the bedside clinical worker falls into a couple of areas and I'll give some examples below.

1. I should be providing direct care to a patient or should have provided recent care in order to look up their chart. Some of you may remember the healthcare workers that were fired for accessing Brittney Spears medical information. They were likely fired under this provision.

2. I can't share any specific information (name--never, age, and complaint) listed together in areas where other's could become aware of the patient's visit. This would include areas like social media (a big no-no). When cases are presented at medical conferences, generally all patient information is blacked out (say on x-rays). And the patient is only spoken of in general terms. Such as: 16y/o presented to the ER for evaluation of neck pain. Now, across the USA for one day, probably several patients presented with this complaint so how do you know which one it was?

3. I shouldn't be sharing patient information with my spouse unless he has provided direct care to the patient as well. Therefore, since my husband is an accountant, I can't say--- "Oh, by the way our neighbor's daughter was seen for a broken arm today in the ER." Unless I've asked the mother specifically if it's all right that I mention this to my husband, I have violated that patient's rights by sharing that information with my spouse. Working in pediatrics, I've been in the situation often and don't mention the visit at all when home.

4. Requests for information about a patient from the media generally go through the public relation's office. This tends to happen more off hours, a reporter will get through to the ER desk and begin to ask questions. Most, if not all hospitals, are very firm that all media inquiries go through public relations. This allows them to control the message.

5. Patient information cannot be given over the phone unless specified by permission. This is why, when you fill out those HIPAA forms at your doctor's office, they generally ask who they can talk to and what kind of information they can share. Perhaps you don't want your husband to know why you were at the OB's office. A caveat to this is giving information to your personal physician who is following up on your ER complaint. We will generally give specifics for this because they are providing your follow-up care.

Next post I'll talk specifically about HIPAA and minors.

Author Beware: Seasonal Illnesses

One thing to keep in mind when you're writing a novel is that some illnesses are seasonal. So if your book covers an obvious time of year-- say the summer. It may behoove you as an author to be aware of the illnesses that are and aren't around.

Croup: AKA laryngitis. Used to be seasonal but we typically see it year round. No time restrictions needed here.



fyi.utah.edu

RSV: The leading viral cause of bronchiolitis typically starts in late fall, early winter and lasts approximately 20 weeks. This is what healthcare professionals happily (maybe?) term "respiratory season". It means gowns, gloves and masks need to be worn for patient's that present with cough and fever. Another fact to keep in mind.


Influenza: Influenza is truly a respiratory illness and not a gastrointestional (GI) one. You know an author has thoroughly checked their facts when they have a summer illness with vomiting and diarrhea and don't call it influenza. This is why flu shots are given Sept-Nov... to help prevent the transmission of this illness.

Keep seasonal illnesses in mind when you're writing a novel that occurs during a specific time of year. It may behoove you to ask if that contagious illness you're killing off your characters with would actually occur during your time frame.

Have you used a contagion, known or "created" in your novel?

Author Beware: Implausible Killing Methods

I know the difficulty writers face at having to come up with unique and unusual methods of killing off their fictional characters. Hence, the constant hunt for lethal, undetectable poisons.

One popular author came up with the following scenario for his serial killer. I read this detailed scene with great interest but in the end, the implausibility of the scenario kept me up that night. I continually analyzed the scene in my mind and wondered if the author might have posed the question to a medically sound person as to its plausibility.

In short, essentially the killer drilled holes into the victims ankles to drain her blood. This would be death by exsanguination. But then, plugged up the holes with glue. Proceeded to string the victim up. Then pulled off the glue plugs so the victim would hemorrhage to death.

Inventive... yes, absolutely. Haven't read anything quite like it. Plausible... not really. Here's why.

In order to bleed to death quickly, a major vessel needs to be disrupted. Preferably an artery. Your heels are not very vascular meaning they are not rich in blood supply. Imagine a cut on your heel and the same cut on your head. Which will bleed more swiftly? There are arteries in your feet. They are located on the top of your feet and near the inner malleolus which is the knobby bone on the inside of your foot. Drilling through the ankle into the heel likely will not catch either of these major arteries.

The other issue. Plugging up the holes. Any time bleeding is stemmed, the blood has a chance to clot. Now, in this novel, the killer was very busy for quite some time hoisting the victim. I think enough time for the victim's blood to clot. Therefore, when the plugs were removed, I think very little bleeding would have actually occurred.

What scenarios have you found in novels that are implausible? Were they enough to draw you out of the story? Please, keep the author's name and book title off any comments, otherwise they will be deleted.

Author Beware: Use of Medical Equipment

I'm an avid reader. Don't you have to be as a writer? I have to admit, there are a few authors I lean toward. Generally, I'll read most of what they publish.

I also have an issue. I know that it can be very hard to get medical details right in a manuscript. I faced this challenge when I wrote an OB scene and had an OB nurse review it. To put it mildly, she was displeased with what I wrote. I was actually relieved to find that out during the editing phase rather than have a whole lot of obstetrical nurses throwing my novel into the trash because they were offended at something I'd written.

Usually, I'll give a little leeway to those I read... a little. For instance, using EKG instead of ECG is okay... not great but I generally peruse by without much thought.

I was reading one mega-bestselling novelist when he began to write a hospital scene. The character had been beaten up fairly well and there was a description of the medical equipment that was attached to his body. It read something to the effect that, "He had nasal cannulas in his nose."

A nasal cannula (nasal prongs) is an oxygen delivery device. It's very common. The correct way to note the use of this piece of equipment would have been to say, "He had a nasal cannula in his nose."

The way the writer phrased it immediately brought an image to my mind of two of these stuck up his nose. Now, my story bubble has burst and I'm re-reading this sentence to be sure that's what he really said.

If you're unfamiliar with medical equipment, run the scene by someone familiar with its use to avoid simple mistakes like this one.

Author Beware: Wrong Medical Procedure

Recently, I was reading a novel by a well-known published author. I'm enjoying the story line a lot which is preventing me from putting the book down and reading another one.

This was the written sentence. "We took him to the OR and drilled a hole in his head just in case there was a subdural hematoma."

WOW! There's a lot going on in this single sentence. A lot that is medically inaccurate and I'll tell you why.

First, a subdural hematoma is a "collection of blood on the surface of the brain"-- between the brain and the skull.  The volumes of this blood collection vary and do not always need intervention. However, if the volume of the blood collection is large enough, it can actually push on the brain and cause its contents to shift. This is termed herniation. In that case, surgical evacuation of the blood clot by a neurosurgeon is the preferred treatment.

Drilling a hole in a patient's head is generally done for two reasons. The first is to drain cerebrospinal fluid and the second is to monitor intracranial pressure or ICP. So, even if the patient did have a subdural hematoma, this likely would not be therapeutic treatment.

The next issue is the just in case part. With CT scanning readily available (even at most smaller hospitals), there should be no reason to wonder whether or not the patient has a subdural. This particular patient took a severe beating to his head and has neurological deficits. Standard treatment would be to do a CT of his head. Then the medical staff would know for sure what they were dealing with.

Which leads us to the last issue. The doctor performing the surgery was an orthopedic surgeon. This is not in their realm of specialty. Drilling a hole in someone's head goes to the neurosurgeon. I can't think of many ortho types who want to be mucking around near the brain. And if they are, they've likely consulted a neurosurgeon.

Scope of practice issues come up commonly in manuscripts. Either the act done is outside that character's scope of practice. For example, an EMT performing a C-section is outside their scope of practice. Or, a specialist is doing something they usually don't do as in this case.

To be clear, I do think it is okay that a fictional character does something they're not supposed to do like operating outside of their scope of practice. This can add great tension and conflict to a scene. Imagine an EMT attempting to do a C-section to save a baby's life when the mother has died. What I would be sure to do is make it clear that the character knows this is outside their scope and is troubled by doing it or maybe cavalier about doing it but that they know where the line is.

You can also take the other bend, the character doesn't know and does it anyway. In this instance, there should be discussion from other characters that this person is known for operating outside their scope and presents a danger to patients. Then, your reader will know that your medical knowledge is good but it is the character running amok.

What do you think? How would you have a character do something outside their norm that won't turn off your reader?

Author Beware: Arterial Bleeding vs. Venous Bleeding

I'm going to start doing these "Author Beware" posts every now and then. When you see that heading, it signals I'm doing a post on something a published author has written that medically is questionable. Now, I won't name the author or book, just the situation. So, if you know the book and/or author, please keep it close to the vest. This is merely for learning purposes.


geology.com

In two novels recently, I've come across inaccurate descriptions of venous versus arterial bleeding. One novel in which a character had slit his wrists clearly described arterial bleeding but called in venous bleeding. Another novel described a puncture wound to the neck and a "geyser" of blood from the wound yet the character made it to the hospital with a dressing around his neck.

First, what is the difference between arterial and venous bleeding? A short anatomy lesson first. Arteries are on the forward side meaning this is blood that has just left the heart. In order for your heart to get blood through the body, it has to pump. The heart's pumping is something you can feel... it's called your pulse. Whereever you feel your pulse is an artery.

Venous blood is on the return side. This is blood that has off loaded its oxygen and is on its way back to the lungs. There's not as much pressure, per se, in those vessels.

When you puncture an artery, it spurts, pretty dramatically, with each heartbeat. I saw a demonstration once of how long it would take someone to "bleed out" from an untreated arterial bleed to the knee which houses the popliteal artery. Now compared to some, this would be a smaller sized artery compared to your aorta. Any guesses?

About three minutes.

Venous bleeding doesn't have the characteristic spurting with each heartbeat. It generally oozes though it can ooze quite a bit. Venous bleeding can also be deadly if there is enough of it left untreated.

Arterial bleeding is generally harder to control than venous bleeding. You have to apply a lot of pressure to get it to stop. Hence, my dismay at how a character who sustained an injury to his neck, likely the carotid artery, could have made it to the hospital with a simple dressing in place.

What do you think?