Author Question: Disease for Infant

My good friend, Candace Calvert, drops by today with a medical question. Even though she is a former ER nurse extraordinaire-- pediatrics was not her specialty so she is doing what medical people do best-- consult an expert and I am happy to help out with the help of one of my physicians.

Candace writes inspirational romance with a medical backdrop. I happily endorsed, Rescue Team, releasing May 1st which is book #2 in the Grace Medical Series. Hope you'll check out all of her books. She is one talented lady.

Candace Asks:

I need a disease/disorder for a 6 month old baby that would require hospitalization and is hereditary.

Jordyn Says:

Okay, first I have to confess that I got the answer to this question from a physician co-worker who is an encyclopedia for crazy medical conditions. If your child is that zebra in the forest, she will figure out what it is so thanks Cathy for this answer.

A perfect condition would be a Fatty Acid Oxidative Disorder. In this case, a long chain mixed fatty acid oxidase deficiency. Now, before your eyes glaze over with that-- I could never write that-- checked out look like I may have had in high school algebra you could simply say the child had an inherited metabolic disorder.

The child would appear to be normal and all body symptoms normally functioning until something happens to cause the child to fast such as stomach flu (gastroenteritis) that would cause the child to stop eating due to vomiting.

This definition comes from the follow link:

Definition: Fatty acid oxidation disorders are inherited conditions that affect the way a person’s body breaks down certain fats (fatty acids). A person with a fatty acid oxidation disorder cannot breakdown their stored fat for energy. Consequently, the body begins to fail once food the person has eaten runs out. In addition, fatty acids build up in the blood. In the case of fatty acid oxidation disorders, the inability to break down fats for energy and the build up of fatty acids can cause serious health problems.

In a normal, functioning body, when you no longer are taking in food, your body starts to metabolize muscle and fat for energy. This is actually the basis of some diets that cut out carbs in order to get you to burn fat. It puts your body in a state of "ketosis" which isn't necessarily an awesome thing-- but I digress.

When the body is burning muscle and fat for energy, you get a build-up of ketones in the blood. We can actually see the body is burning ketones by performing a urinalysis that shows ketones.

In this case, what would actually point the physician to think about this particular metabolic disorder is the absence of ketones in a state where the patient would normally be ketotic. For instance, the blood sugar would be dangerously low (10-20-- where you could actually seize.) Normal blood sugar is 60-100. When the blood sugar is low, the body should naturally go to protein (muscle) and fat for energy because it is very self serving in wanting to stay alive. On the urinalysis, there would be absence of ketones showing the body's inability to breakdown these tissues.

Treatment would include infusing a high sugar solution (like D10).

Top Three Pet Peeves of Pediatric ER Nurses

At least my top three!

This week, I'm highlighting some blog posts that I did for Erin MacPherson's Christian Mama's Guide last year. Some of you may not know but I am a real live pediatric ER RN. As always, these posts are meant to be educational and do not replace a doctor's visit if your child is ill.

Erin has a WICKED sense of humor and is releasing a series of books this spring so I hope you'll keep an eye out for them.

Here’s a look into the mind of the pediatric ER nurse. Don’t we all have pet peeves when it comes to our jobs? Of course… the ER nurse is no different. Often times, these are not mentioned in “public” as we don’t want to offend families. But, in honesty, there are some things parents do that drive us crazy. Here are a few at the top of my list.

1. Calling medicine candy. This is a big no-no for us pediatric nurses. We really don’t want kids to associate taking medicine with the fun of having candy. Candy is good. Candy is fun. Candy is generally not lethal if you eat too much. Medicine is far different from that. So say something like, “This tastes sweet.” Or “This tastes like orange.”--- but don’t associate medicine with candy in the same sentence.
2.  Children not wearing helmets. I’m amazed at how many families come to the ER over concern for head injury after a fall off of (insert something with wheels here) and their child wasn’t wearing a helmet. First question: Do they have one? Often times the response is, “Yes, I just can’t get him to wear it.”

First off, as a parent, set the example. Are you wearing your helmet when you ride your bike? Second, from the moment your child is on anything with wheels, they need a helmet. Yes, even when they’re on their tricycle. This will institute a habit and an expectation—just like wearing a seatbelt.

Secondly, be firm. If they don’t wear their helmet, they lose their wheels. Parent, “I can’t keep him off his bike.” Well, then the wheels come off the bike. The skateboard is locked in the trunk of your car. Be firm.

It only takes one bad head injury for devastating effects. Don’t risk it.

3. Smoking. Secondary smoke is a big health risk for kids. If you smoke, you need to stop. Smoking outside, unfortunately, doesn’t help. Yes, even if you have a “smoking jacket”. If I can smell smoke, the particles are on you and can even be enough to trigger an asthma attack in kids. If you are a smoker, talk to your pediatrician about resources your state might have to help you quit. Smoking during pregnancy has been linked to the development of congenital heart defects in infants along with a host of other problems.

Now, you tell me, what are some other pet peeves you think a pediatric ER nurse may have? Are you offended by reading these?

ED Treatment: Peds versus Vehicle (2/2)

We’re continuing with Mart’s question. Briefly from last post, a 16 y/o has been struck by a car. What would medical treatment be? She bounces off the hood and these are her injuries. Her elbow stung and her right leg turned back and blue almost instantly. Right hand is swollen. Her shin looked like a giant Easter egg lived under its skin.

EMS Response: Dianna

Contusion is the medical term for bruise. Contused areas don’t color immediately; it takes time – hours to days, sometimes only minutes depending on the injury and how easily the patient bruises, so include in her dialogue she bruises easily, but have most of the coloring appear later (not at the scene). However, patients feel contused pain immediately and a hematoma (mass swelling) can develop within seconds or minutes. The Easter egg you describe is called a hematoma.

Like human crutches, we’ll assist her inside the ambulance or we’ll place her on our stretcher and wheel her inside our ambulance. We typically assist the walking wounded instead of using the stretcher. Once inside our ambulance, I’ll ask her to lie on the stretcher. I’ll hook her up to our cardiac monitor to obtain a 12-lead just to verify her heart is functioning normal (heart rhythm is normal).

I’ll insert her index finger in a pulse ox to obtain her SPO2 level (blood oxygen saturation). I’ll calculate her breathing rate and heart rate and I’ll take her blood pressure and evaluate her skin and pupils. I’ll perform a rapid trauma assessment, head to toe, to ascertain full extent of injury.

I’ll disinfect all abrasions and control any bleeding. I’ll splint any suspected fractured bones or joints. We'll offer her Fentanyl (pain reliever) but we'll only administer it if she allows us to transport her -- we can't inject pain meds and then leave the patient (not transport to an ED).   

To clear the patient of C-spine immobilization: I’ll perform an examination of her neck, spine and all extremities, and if she denies any pain, tingling or numbness and I find no abnormalities, then it’s suspected the patient didn’t suffer any neck or back injury, thus no cervical collar or back boarding is necessary.

ER Care: Jordyn

When the patient arrives in the ED, if they are able to walk (a patient in C-spine precautions precludes this), we first obtain a weight. This is important in pediatrics because medications are dose dependent on that weight.

We’ll take report from the ambulance crew. Set of vital signs. Connect to a monitor. Assess pain level. Check IV site to make sure it is patent (lines can come out upon patient movement/transfer). Check splints to make sure distal part of extremity is getting good blood flow. The nurse will listen to her heart and lungs. Quick neuro exam. We’ll likely x-ray the right elbow, right hand and right lower leg. Even though suspicion of fracture might be minimal, the ED doctor has to disprove otherwise. Wounds cleaned and dressed.

Tetanus shot if none in the last five years. This is done for injuries that break the skin. Otherwise, you're okay for ten years.

If the area is fractured, a splint will be applied. If no fracture, an ace wrap may be applied for comfort. It is important to note that often we will splint even if the x-ray is negative. This is both for support, comfort and compression. And also if the radiologist comes back and reads it as positive. The patient is instructed to leave the splint in place for about a week and if the extremity is still bothersome, to seek another evaluation of the injury. Some fractures won’t show up on x-ray initially but will later when they begin to calcify.

The patient is sent home with R.I.C.E instructions. Rest. Ice. Compression (leave your splint on). And Elevate. Generally, over-the-counter Ibuprofen is sufficient for pain control.

Dianna Benson: EMS Treatment of a Minor (1/2)

Mart asks: My MC is 16 yrs old. She gets hit by a truck. She has road rash. Right leg turned black and blue. Shin welled up. But other than feeling like she literally was hit by a truck, she is okay....she thinks. What would most likely occur after an incident like this? In short, how can I make it so a 16 yr old girl who has been hit by a car, stalls at home before her Mom takes her to the ER?

I hope there is a way.

Dianna says:

A 16-year-old can accept EMS treatment and transport to a hospital. However, a 16-year-old cannot refuse treatment and/or transport – EMS has a refusal form that requires a signature from the patient, a minimum of age 18, or from a parent or legal guardian of a minor aged patient, 17-years-old or younger. EMS will not leave a patient at the scene until we obtain a signed refusal form (we wait for as long as it takes to obtain that signature).

It’s not uncommon for patients to refuse an ambulance transport to avoid additional medical bills and then have someone drive them to the ED.

From your scene description, it sounds like the patient was a pedestrian stuck from a truck at low speed, propelling her body in the air slightly; her leg skidded on the road, stopping her.

A pedestrian struck by a moving vehicle is a serious mechanism of injury thus a high priority trauma. EMS will encourage both treatment and transport by explaining to your patient she may have internal injuries.

I actually say to patients, “I don’t have x-ray vision or CT scan capabilities inside my ambulance, so I’m unable to verify if you’ve sustained internal injuries or not.” If transport is still declined, I obtain a signature of refusal from a parent or legal guardian (the uncle wouldn’t be enough). The way around this legal issue is for the MC to call her mom and EMS waits for her to arrive on scene.

Was the truck driver at fault for hitting the MC? If the driver is legally at fault, then most patients tend to accept EMS treatment and transport (think law suit). Regardless of any pending law suit, I think the uncle would insist the main character be transported.

Once the mom arrives on scene, I find it unbelievable (and not likeable or smart of the mom) that a mom would refuse transport to a hospital for their injured teenager struck by a moving truck as a pedestrian. That’s a serious mechanism of injury (most car accidents are minor, but being hit by a car as a pedestrian is serious). However, if you prefer to avoid an ambulance ride in your story, then write in the following: 1) Keep the injuries extremely minor – EMS finds no abnormalities beyond right lower extremity minor swelling and abrasions with slight oozing blood.  2) All her vital signs are within normal limits. 3) The patient assessment from EMS cleared C-spine immobilization (backboard and neck collar).

However, since the mechanism of injury is significant, in order for those three above points to be believable, you’ll need to write in the following: 1) The truck was moving at extreme low speed (like 5 miles per hour); it’s amazing how much damage just 10 miles per hour causes. 2) The truck is small or it’s a small car. 3) She wasn’t thrown far in the air (height or distance) and didn’t hit anything else. 3) Her behavior and signs and symptoms indicate she suffered no injuries beyond minor contusions and abrasions. 4) She’s adamant against a trip to the ED.

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After majoring in communications and enjoying a successful career as a travel agent, Dianna Torscher Benson left the travel industry to write novels and earn her EMS degree. An EMT and Haz-Mat Operative in Wake County, NC, Dianna loves the adrenaline rush of responding to medical emergencies and helping people in need, often in their darkest time in life. Her suspense novels about characters who are ordinary people thrown into tremendous circumstances, provide readers with a similar kind of rush. Married to her best friend, Leo, she met her husband when they walked down the aisle as a bridesmaid and groomsmen at a wedding when she was eleven and he was thirteen. They live in North Carolina with their three children. Visit her website at http://www.diannatbenson.com 

Not Kidding Around: Alina Adams

I'm pleased to host Alina Adams today as she writes about the importance of research and how she forayed into worlds she didn't have a clue how to write about-- including mine-- pediatric medicine.

Welcome, Alina!

My first two published books were Regency romances, set in Regency England (think Jane Austen).

I know nothing about Regency England.  (I am of the mindset that nothing romantic could have possibly happened prior to the invention of indoor plumbing). 

Yet, the AVON editor who rejected my submitted contemporary romance in 1993 told me that new authors had the best chance of breaking in by writing a Regency romance.  So I did some research (i.e. I read a book called “What Jane Austen Ate and Charles Dickens Knew”), and a Regency romance I dutifully wrote, “The Fictitious Marquis,” followed by “Thieves at Heart.”  (I was later informed by a copy editor that I’d missed the true Regency period by several decades.)

My first contemporary romance, “Annie’s Wild Ride” featured two Air Force pilots.  I know nothing about Air Force pilots.  (I’m not even a big fan of flying.  In fact, my entire writing career comes down to wanting to write books that can make your cross-country flight feel shorter and less arduous.)  I also know nothing about the Air Force Academy in Colorado, or the engineering of roller-coasters, all of which play a big part in the story.

So, once again, I read a book.  (Luckily, while I was writing “Annie’s Wild Ride,” Kelly Flinn, one of the few female pilots in the Air Force was being drummed out for adultery, so there was a great deal of relevant information on the news: http://en.wikipedia.org/wiki/Kelly_Flinn).

My second contemporary, “When a Man Loves a Woman,” in the initial stages was merely the story of two doctors.  Turns out, doctors need a specialty.  So I – what else? – read a book.  Several books.  And I learned several fascinating things.

Namely that children are not small adults.

But that not everyone in the medical profession seems to be aware of that.

My characters, Dr. James Elliot and Dr. Deborah Brody (best-friends since medical school and probably in love, too, but Deb was kind of already married when they met – oops) are a pediatric trauma surgeon and a pediatric neurosurgeon, respectively.

And it was through them that I learned such things as that not only do pediatric patients require custom-built, smaller medical equipment, but that procedures that work perfectly well on adults might have the opposite effect on children.

One example that really sticks out in my mind is that an adult patient suffering from heavy bleeding can have his/her spleen removed, and go home none the worse for wear.  A child can undergo the same procedure and also go home seemingly perfectly healthy.  Only to die from a cold down the road because their immune system has been completely compromised.

The most important thing I learned courtesy of Drs. Elliot and Brody was, when faced with taking your child to an emergency room, you should do your best to make sure that the hospital has a pediatric emergency room.  Both for the specialized equipment and for staff that knows about the spleen issue… and a million others.

It’s a lesson that came in handy with my own child last year.  In NYC, we are fortunate in that we have quite a few hospitals to choose from.  So when it came time to decide which one to go to, I did have a moment of freezing.

And then I remembered “When a Man Loves a Woman.”  Choice made!  (Another reason to go to a pediatric emergency room: The experienced nurse on duty took one look at my son and, before any x-Rays were so much as ordered said, “His arm’s broken.”  It was.)

“When a Man Loves a Woman” was released by AVON in 2000 as a paperback.  This September 2011, I am re-releasing it as an enhanced e-book.

What’s an enhanced e-book?  It’s a book that offers the same text as the original in electronic form… plus a little bit extra.  In this case, it’s a soundtrack of songs to compliment the story.

Please check out “When a Man Loves a Woman: Enhanced Multimedia Edition” at http://www.alinaadams.com/.

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Alina Adams wrote Regency romances for AVON, contemporaries for DELL and a Figure Skating Mystery series for Berkley Prime Crime.  Her soap opera tie-ins, Oakdale Confidential and Jonathan’s Story were NY Times best-sellers.  Another tie-in, The Man From Oakdale, won the 2010 SCRIBE Award.  Alina is currently working on turning her entire back list into enhanced e-books, spearheaded by Soap Opera 451: A Time Capsule of Daytime Drama’s Greatest Moments.  Visit her at: http://www.alinaadams.com/.