Medical Critique Hostages: One Episode to be Thankful For

Okay, I admit it. I've been beating up on the CBS drama Hostages. So-- since it is Thanksgiving and we're to be thankful I'm going to give a shout out to Hostages for one accurate story line.

Then it will be back to a hard medical critique as there is MUCH to discuss in some of the most recent episodes.

In one of the minor plots, the teen daughter is, of course, pregnant. Her father takes her to an OB/GYN to check the status of the pregnancy and stays in the waiting room.

Accurate portrayal #1: Teens presenting for care related to reproductive issues or sexually transmitted diseases are treated as adults in the sense that they don't have to have a parent present to consent for treatment and should be seen privately by the physician.

During the exam, the physician asks her what all the bruising is about. And, the teen girl does have a suspicious bruising pattern.

Accurate portrayal #2: Suspicious bruising patterns are those that:
1. Can't be explained by the history given (I fell down the stairs.)
2. Are located over non-bony prominences. This teen presented with bruising to her upper arm (from being grabbed) and to her back (from cutting out a tracking device.)
3. Are numerous and extensive.

The doctor becomes suspicious and notifies social services.

Accurate portrayal #3: A physician is a mandated reporter under most state statutes to report a suspicion of abuse. They don't have to know beyond a shadow of a doubt that something is happening but if, in good faith, they are concerned by what they see then a report is necessary.

In a few days the teen is approached at school by a county social worker for questioning.This occurs in episode seven.

Accurate portrayal #4: There would definitely be an evaluation of the teen in private-- away from the parents. The social worker also interviewed the brother, who also had a black eye. Alone. In psychiatric situations involving teens the family is generally interviewed together and at some point-- each member is interviewed alone to get what's really going on.

So on this Thanksgiving Day-- thank you Hostages for accurately portraying management of a family when there is concern for abuse.

Now everyone-- have a safe and great holiday. I'll be working the ER and I don't want to see you ;)!!

Author Question: Police Death Notification

In my writing life, I've met some fantastic police officers. My own brother is a county sheriff close to where I live so I use him a lot for questions. I've also gotten to meet many other great police officers and one was very helpful in giving me a detailed SWAT scenario for my most release, Peril.

Darcie sent me some police type questions and I passed them along to Seargent S. Tarr and he provided the following insight.

Darcie asks:

What I learned so far is that if my Main character (Kelley)'s parents' bodies were found along a hiking trail near Glenwood Springs, the Denver Police would visit her house to break the news since Kelley lives in the Denver area.

Sergeant Tarr: Yes, if a person is found to be deceased the next of kin is notified by the jurisdiction that the person's family is located. They would usually send a marked patrol unit and a victim advocate. We call it a death notification. Sometime the coroner will also go if it’s in the same jurisdiction. 

Darcie: That leaves me now with, since at first this appears to be a hiking accident, where would the bodies be? Coroner? 

Sergeant Tarr: It doesn’t matter if it appears to be an accident or not. The coroner would handle the investigation into the cause of death and police in the manner (like a homicide, scene traffic accident, suicide etc..) So it would be a joint investigation regardless. The only time the coroner and law enforcement don’t do an investigation is if it happens in a hospital or in the care of medical staff. So the coroner would take the body and most likely perform an autopsy. Would be very uncommon for them not to. The coroner would then rule on the cause of death ie: natural, suicide, accidental, etc.. 

Darcie: Would there be an autopsy? 

Sergeant Tarr: An autopsy would be performed by the jurisdiction that the death happened. The pathologist could be from Denver. I know for example that the pathologist from Fort Collins comes down to Denver to conduct autopsies. The Arapahoe examiner has also traveled to other coroner's offices to assist. 

Darcie: Would Kelley have to go ID them even though they had drivers licenses etc on them?

Sergeant Tarr: This depends on if a positive ID can be made with the id or not. Like if their face was ripped off, sorry to sound crude. They can also put their fingerprints through AFIS to see if they can get an ID that way also. Sometimes the family has to ID the body if no positive ID can be made. It is usually the last thing done. Once the coroner releases the bodies it would be picked up by a funeral service. They would transport the bodies back to Denver for the funeral arrangements.

Up and Coming

Hello Redwood's Fans!

This week is Thanksgiving week-- so it's time to reflect and think about all those things we are grateful for. It's hard for me to do right now (now that I'm not thankful) but I have to work Thanksgiving Day and, to be honest, am a little (okay, a lot) grumpy about it. So, I thought I'd write a few things I'd be thankful for if YOU did them so I could actually not see patients that day.

1. Drink responsibly. No drinking or driving. Don't even try it. It's just not worth it. Think about KILLING someone else on Thanksgiving. If you're going to get hosed-- lock yourself up in your own house and give someone else the keys.

2. Watch those knives. It's JUST dinner. Don't let stress, family arguments, and poor time management cause the silver to flash and fly. If you're using the ER as a break from your family then perhaps you should not be spending the day with these peeps. Just cut out the negative energy.

3. Your kids are going to get a belly ache. It's probably not their appendix-- it's constipation related to ALL the carbs they stuffed in their gut in a short time frame. Make sure they're drinking water and some stuff with fiber. They actually WILL eat the good stuff (raw fruit and veggies) if they are TRULY hungry and that's what you offer. Don't let them eat out of boredom. Have them play outside.

4. You are sharing germs. No double dipping, please. Stay six feet away if someone is coughing and don't be afraid to look stupid for wearing a surgical mask.

5. New babies (under 60 days old)-- should be sheltered and protected. Don't let everyone in the world come around and kiss their cute little faces. Tell the uncle who hasn't shaved, showered or brushed his teeth in the last ten years that next year you'll offer up the newest member of the family for a slobbery smoocher.

Okay-- that's my top five. I really do just want to sit around and drink cocoa all day.

For you this week!

Tuesday: SWAT officer S. Tarr drops in to answer some writerly police operational questions. I thought his answers were so helpful that they could help writers everywhere.

Thursday: I've been beating up quite a bit on the CBS drama Hostages lately so I'm giving them kudos for one episode and then it will be back to the medical critique because I cannot help myself. So-- just what did they actually do right?

Have a safe and overly joyful Thanksgiving!

Jordyn

Medical Critique: CBS Drama Hostages 2/2

This week, I'm medically analyzing the CBS drama Hostages. In the previous post, that you can find here, I said I'd give them some kudos . . . and I will . . . I promise, but it will come at a later time because I'm having too much fun dissecting this episode.

These posts do have spoilers . . . you have been warned.

Last post I discussed the first three issues I had with the episode and they are as follows:

1. Gunshot wound victims are at high risk of dying from blood loss-- not heart arrhythmias.
2. Physicians don't carry hospital grade defibrillators in their back pockets. Maybe Tom Cruise does but I digress . . .
3. Physicians are generally not comfortable operating a defibrillator. This is generally a nursing function once the physician prescribes the amount of electricity he wants delivered.

Onward we go.

Issue Four: After the husband is "brought back to life" Ellen, played by Toni Collette, goes about diagnosing his problem. Keep in mind she's a cradiothoracic surgeon. Now, she will have gone through a general surgery rotation but her specialty will be everything above the diaphragm.

Her husband has a wound to the left upper quadrant of his abdomen. She sticks her finger into the wound-- perhaps up to the first knuckle and declares, "Your renal vein has been severed." or something relatively close to that.

Wow. Just . . . wow.

Your kidneys lay in your mid-lower back. I like the image here a lot and it comes from the noted website. I think this website is AWESOME. There aren't any gory pictures but it has several photos of drawings similar to this one that shows the anatomy as it lies under the skin drawn with ink.



This is how we think in medicine. We say . . . "The patient was shot here . . . what is underneath or along the tract that could be damaged." And from that we order labs, x-rays and advanced imaging like CT.

In reality, there is no possible way to diagnose a renal vein severing with a finger probe to the front of the abdomen . . . or to the back of the abdomen. This needs advanced imaging techniques. Now, there is some gross (not as in yucky) techniques that could likely lend to the diagnosis of injury somewhere along the GU tract. Blood in the urine. Perhaps urine leaking out of a wound. But to be so specific needs advanced imaging.

http://meded.ucsd.edu/clinicalmed/abdomen.htm

And I can't imagine suturing that vein closed with the patient awake and moving around. Those suckers are small.

I actually do think there would have been a better injury to give this character's husband that would have been more in her skill set and MORE dramatic and that is the tension pneumothorax.

A tension pneumo could easily happen in a gunshot wound to the chest. The lung is hit and leaks air into the chest cavity. If enough air accumulates in the chest it actually pushes or shifts the chest organs (lungs and heart) to the unaffected side (imagine a balloon blowing up in the affected side.)

Treatment for this type of injury is a chest tube and could be fashioned from something from the home and perhaps something from her medical supplies. You'd need a large size tube-- they are big-- think maybe 1/2 the size of a diameter of a garden hose and come in various sizes. Once placed, she could secure it with sutures and place the end in water lower than the patient so air didn't get back into the chest.

To diagnose-- you listen to breath sounds. There are no breath sounds on the affected side. Tracheal deviation-- which means the trachea is shoved to the unaffected side. There are also temporary measures that can be done until a chest tube can be placed-- like sticking a needle in the chest. Then she could have figured out what she needed to fashion a chest tube.

Often times, when I spend time interviewing an expert, I have always come up with a better scenario, and a more realistic one than what I imagined would be good.