Wednesday, December 22, 2010

Preventing Holiday Injuries

I often get asked, "Are there any injuries specific to certain times of the year?" There are seasons for certain ailments and injures. For instance, kids drown more commonly during the spring/summer (except bathtub drownings are year round). I've only seen fishhooks embedded in not so fun places during the summer. Now, if I were a nurse where ice fishing were popular, then this may be a more year round occurrence. Unfortunately, there seems to be at least one story every year of a house burning down from a Christmas tree fire.

Specific to pediatrics (and adults in some cases), there are illnesses that are seasonal. Flu (the respiratory kind) is prevalent in late fall and winter. The respiratory syncytial virus (RSV) affects infants and children during this time as well. Rotavirus also comes out to play during this time of year. Considering all these illnesses, it's not hard to understand why patient volumes and wait times increase during the winter.

So... stay safe out there and check out this article on holiday safety: http://www.medicinenet.com/script/main/art.asp?articlekey=15239

Hope everyone has an amazing Christmas!

Jordyn

Monday, December 20, 2010

Medical Scene Diagnosis: Christine Lindsay

Christine Lindsay submitted this short medical scene for review. Check out some of the finer points that a medical review can add to your novel. Also, I'd like to wish Christine a very happy birthday today!! She has many exciting things going on as she just received a contract on her novel Shadowed in Silk. Congratulations.

This scene comes from her next novel, Sofi's Bridge:

Neil pulled back the man's eyelids. The pupils dilated equally. He ripped open the blood soaked trouser leg, trying in vain to wipe away the seepage. It was as he feared, a bullet wound. 
           Neil picked up the man to take him to the shack. The dog bounded beside him. Sofi ran before Neil as he staggered with the weight he carried.
            “Clear the table,” he ordered.
            She helped him lay the patient on the table covered by an oil skin cloth.
            Outside, on the track the locomotive slid past. Red, white and blue rosettes, and bunting beribboned the front of the cow catcher. Steam rose from under flanged wheels as the locomotive ground to a stop outside the shack.
            On the opposite side of the table, with the patient between them, Sofi drooped her head.
            Neil bent over to examine the wound. He released a sigh of relief that jarred with frustration. The bullet had missed the femoral artery and was lodged in fatty muscle. The patient would be alright. His skin was dry and warm. Though he gritted his teeth in pain his pulse was strong and steady. With the pupils dilating normally, and the chest rising and falling evenly at a normal rate, this man did not need immediate surgery. Neil could have very well left him in Sofi’s hands as she’d begged him, and been deep in the forest by now.
My first comment is about pupils A normal pupillary response to light is to constrict, not dilate. You can check this out for yourself on a friend with a low powered flashlight. Shine the light at their eyes and you should see the black part constrict. Both pupils should constrict together, equally, even when the light is aimed at only one eye.
My second thought is the description of the bleeding. For a bullet essentially lodged in fat tissue, the bleeding sounds more severe than what I would expect. Though, venous bleeding can be fairly significant as well. You can die just from venous bleeding. Overall, I think as a writer you would have some latitude here. I've included some other descriptions that are highlighted that could clarify the patient is not in shock.

Any other thoughts for Christine? 
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Christine Lindsay is a writer of historical romance. In the case of her debut novel SHADOWED IN SILK which will be released in summer 2011 by WhiteFire Publishing, Christine's writing leans more to a historical novel with a strong love story. SHADOWED IN SILK won the 2009 ACFW Genesis award for Historical under the previous title UNVEILED. Christine is currently at work on SOFI'S BRIDGE which won 2nd place in the 2010 RWA Touched by Love contest and which is clearly a Historical Romance. Christine's true-to-life experience as a birthmother--a woman who relinquished a child to adoption--is found in the Focus on the Family book, Thriving as an Adoptive Family. The entire story of her relinquishment and reunion with her birthdaughter 20 years later can be found in book form on her blog. Christine lives in British Columbia, Canada with her husband and grownup family close by. Her cat, Scottie, is her chief editor as he's always at her side. Find out more about Christine’s forthcoming novel at: www.christinelindsay.com/2010/11/unveiled-long-awaited-announcement.html.


Friday, December 10, 2010

Medical Question: Burns

Jennie Atkins poses this question:

What happens when someone gets burned - what do the EMT's do on the scene? The story line involves the explosion of a crosswired electrical box.  Two individuals are burned.  First, the man who threw the switch is thrown onto the floor and sparks are showering down on him and his clothes.  He is pinned beneath a shelf that he knocked over.  The second man takes his jacket and tries to put out the flames while others pull the shelf off the man on the floor.    The second man's arm and hand are burned trying to put out the fire, and keep the sparks from falling on the man on the floor. 

I have the paramedics taking the first man to the hospital - I describe very little about his condition.  However, the hero is attended by the heroine who is an EMT.  His burns are secondary. Would he have to go to the hospital?  Get a tetanus shot - if he needs one?

Answer:

The first distinction to make is that there are several different types of Emergency Medical Service (EMS) providers and their level of responsibility to this patient will be different. An emergency medical technician (EMT) generally provides basic first aid, CPR, can administer oxygen and can assist the patient in giving their own medications (like an asthma inhaler or nitroglycerin tablets). A paramedic does more advanced medical procedures and gives drugs. The level of your provider will need to be clear in the medical care they can provide.

For EMT's, in general, burn care is as follows:

1. Remove clothing from the burn that is non-adherent.
2. Remove any constricting items. For instance, if the burn is on the ring finger, you would try and take the ring off.
3. Cover burn with a cool, wet, clean dressing. This will help control pain.

If you have a paramedic responding-- it is possible that an IV could be started and the patient could get IV morphine for pain.
marissanicole77 /Photobucket

If the character is burned by the electrical current, this poses a whole new set of problems. I get the feeling he is burned by the electricity because you mention that he has been thrown back. Electrical burns typically have an entrance and an exit wound... say the hand and the foot. The electricity enters one part but has to exit somewhere. The other problem with electrical burns is that your heart pumps based on an electrical conduction system. An electrical burn can injure the electrical conduction system of the heart and we will look very closely at whether or not the heart sustained injury. The issue with electrical burns is that the damage is often unseen because the electricity will injure you internally but we can't see it externally except and the entrance and exit sites.

The other thought was the extent of your patient's burns and this would make a difference in their medical care. Burns <15% body surface area (BSA) would get cool, moist compresses. However, burns > 15% would get dry, sterile dressings. The reason for this is that burn patients have lost their skin integrity. Your skin helps your body maintain its temperature. Some consider it the largest organ in the body. When you burn >15% and apply cool, wet dressings, this can pull enough heat away from the patient to cause them to become hypothermic. We actually have to help them maintain their body temperature by cranking up the heat in the room or using other warming techniques.

Your patient will have to go to the hospital. Initial ED treatment would be IV placement, fluid resuscitation (there is a formula we use for this-- depends on the burn percentage), pain medication (like morphine) and likely consulting with a burn center to help determine his course of treatment. Tetanus shot would be updated if he hasn't had one in the last five years.

Did you know that paramedic protocols are relatively easy to find online? Here's one that I like: http://web.me.com/dmemsmd/DMEMSMD/Welcome.html. Also, here is a link if you need a diagram to help you estimate how large your character's burn is: http://www.primary-surgery.org/ps/vol2/html/sect0105.html. You can find additional references by typing in at Google University: "paramedic protocols" and "burn charts".

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Jennie Atkins, a Software Engineer by trade a writer by desire, lives in the small rural community in eastern Ohio along with two spoiled yellow labs. An avid gardener, she also loves to make quilts and sings at her local church.  Jennie has a B.S. in Information Technology Management from Kaplan University and is an editor for MBT Ezine Magazine’s Let’s Shout It Out column. Along with her Ponderer’s Blog entries at http://mbtponderers.blogspot.com/ you can visit Jennie at her website http://www.jennieatkins.com/.

Friday, December 3, 2010

Physical Restraint of Mentally Ill Persons

Isn't a medical scene more dramatic when you get to restrain someone? However, to ensure your scene is medically accurate, an understanding of the law and the limitations on using restraints is important. Of course, evil characters can do away with the law. That's your lattitude as a writer! I'm pleased to host Patti Shene and she shares her expertise from working as a psychiatric nurse. You can learn more about Patti by visiting her website at http://www.pattishene.com/.


For a long time, restraint was used as a means to control the unpredictable and sometimes violent behavior of mentally ill patients. However, over time, the courts have recognized that these persons have an inherent right to freedom from inappropriate use of physical or chemical restraint.

The Supreme Court acknowledged, in the 1982 case of Youngberg vs Romeo, that the use of restraint severely inhibits personal liberty. They concluded the use of restraint should reflect “the exercise of professional judgment.” However, this statement encompassed a broad range of views that resulted in a nebulous interpretation.

Over the past decade, it has become clear that restraint and seclusion can legally be used only as a method of last resort when the patient is an imminent danger to himself or others.

Suppose you have a character who meets this criteria for “imminent danger to himself or others”. First, let me describe the type of physical restraint I am familiar with (pictured above).

Physical restraint consists of four leather cuffs placed around the wrists and ankles of the patient. The cuff has adjustable sizes and is fastened with a leather belt that passes through a metal loop on the cuff. The belt is then secured to the frame of the bed and locked in place. The belt can only be released, or opened, with a key.

The use of restraint should be considered a psychiatric emergency, and not used for convenience of staff or as a form of “punishment” for inappropriate or unacceptable behavior. There are many safety issues to consider when a patient is placed into physical restraints.

A nurse must always be present to assess the need for restraints. A patient can be physically contained by staff members prior to the arrival of the nurse, but only if there is an imminent danger to the patient or others.

Physical restraint without the use of an external device should adhere to strict guidelines. Cornell is one such method, a procedure that incorporates three staff members and greatly reduces the risk of injury.

The patient should always be physically contained face up to prevent asphyxiation or choking.

No cloth, clothing, or other restrictive material should ever be placed over the face during a restraint procedure.

Once the patient is placed into physical restraint, is imperative that circulation be maintained. If the caregiver’s finger does not fit comfortably between the cuff and the patient’s skin, the cuff is too tight.

A caregiver must check the patient at a maximum of fifteen (15) minute intervals.

The emotional needs of the patient must be met at all times.

Hydration and toileting needs must be met every two (2) hours.

A patient should never be left alone in a room with a door open after restraints have been applied. This would expose the patient to possible assault or injury by another patient.

The nurse must notify the physician and obtain a telephone order for restraint not later than one hour after the restraint has been initiated.

The dignity and privacy of the patient must be maintained at all times during the restraint procedure. Never is the patient to be teased, taunted, screamed at, intimidated, or in any way physically or verbally abused during the application or confinement of restraints.

If a personal issue exists between the patient and a particular staff member that could result in the violation of these basic rights, that staff member should immediately be removed from the situation.

In the case of child restraint in a residential child care facility, the parent/guardian must be notified as soon as possible that the intervention has taken place and the behaviors that led up to it.

Reevaluation of the patient in restraints, according to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is 4 hours for adults ages 18 and older, 2 hours for children ages 9-17, and 1 hour for children under age 9.

The patient must be released from restraint as soon as he/she is calm, cooperative, and able to maintain control. He/she must be able to commit to display safe behavior toward himself and others.

Several incidents across the country in recent years resulting in serous physical or psychological injury or even death have brought national attention to the issue of physical restraint. Do your mentally ill character justice by knowing the legality of how they should be treated when restraint is warranted.

Source material found at:


http://books.google.com/books?id=f_HYjDUArkMC&pg=PA87&dq=JCAHO+%2B+restraint+%2B+hours&hl=en&ei=nzvwTPb5OML_lge-v4zXDA&sa=X&oi=book_result&ct=result&resnum=1&ved=0CC0Q6AEwAA#v=onepage&q=JCAHO%20%2B%20restraint%20%2B%20hours&f=false

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Patti is a 1969 graduate of a state nursing school in Long Island, New York. Her exposure to state hospital surroundings led her to choose a career in psychiatric nursing. She is a Veterans Administration Hospital retiree and also worked at Colorado Boys Ranch, a psychiatric residential treatment center for several years. Retirement allows her to pursue her interest in writing. She currently fills the position of Executive Editor for Starsongs Magazine, a publication of Written World Communications for kids by kids.