Monday, January 31, 2011

Civil War Medicine: Part 4/4

We're finishing up this Monday with Erin Rainwater's post on Civil War Medicine. Thank you Erin for all of this wonderful information. I know I learned a lot. What's one new thing you discovered?

Civil War Medicine, Part 4

In Retrospect: Hapless or Heroic?


History has not always been kind to Civil War practitioners of medicine. The methods discussed in the previous posts seem barbaric to us now, and the lack of medical knowledge regarding foundational principles such as asepsis, infection and sanitation is regarded as tragically antiquated. Their twenty per cent mortality rate is unacceptable by today’s standards. More horror stories abound. From our retrospective and often condescending viewpoint, we smugly judge one century’s standards by the current set. This is not only an unfair but a flawed verdict. The inadequacies of those medical care deliverers have received considerably more attention than their accomplishments, which were many.

If judged by the standards of their day, Civil War doctors and nurses should be hailed as remarkably successful.  With the existence of bacteria still only theoretical, with the available instruments and anesthesia, and with the indescribable numbers of patients inflicted upon them, the fact they saved lives in such unhoped-for numbers is a credit to their skill, creativity and tenacity.

In the war that preceded this one, the Mexican-American War, ten men died of disease for every one killed in combat. During the Civil War, that ratio was reduced to 2:1. That alone is measurable evidence of an enormous advancement in medical care in the span of under two decades, much of which came about as a result of the war. The creation of frontline field hospitals, ambulance services, and the utilization of female nurses should cause modern historians to conclude that the maligned medical practitioners during the Civil War should be reckoned as heroic, not hapless. Their crude system of triage, setting aside men wounded through the head, chest or abdomen because they would most likely die seems brutal, but with the knowledge and little time available, it allowed surgeons to save those who could be saved. Modern mass casualty triage is not so far removed from this practice.

Aside from medical care administered to the living, advancements in post mortem measures took place as well. Prior to the war, embalming was usually only done to preserve specimens for scientific study. Because many families of killed soldiers desired to bring them home for burial, embalming became more commonplace.

I have only skimmed the surface in relating how the War Between the States necessitated numerous adaptations in the delivery of medical care, and how we benefit even today from some of those changes. These are just some examples of not only medical but also the many moral and social advancements that came as a result of the American Civil War. I truly hope these four weeks have been educational and entertaining, and that perhaps this information will help you gain a greater appreciation of our sesquicentennial commemorations over the course of the next four years.

REFERENCES:

Burns, Stanley B., MD, FACS, “The Naldecon Gallery of Medial History,” Bristol Laboratories, © 1987.

Civil War Manuscripts, Library of Congress.

Downs, Robert B., Books That Changed Amercia.

Miller, Francis Trevelyan, ed., The Photographic History of the Civil War, Prisons and Hospitals

Ward, Geoffrey C., Burns, Ric, and Burns, Ken, The Civil War, An Illustrated History. Alfred A. Knopf, Inc., © 1990.

The Day Richmond Died.





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Erin Rainwater is a Pennsylvania native whose trip to Gettysburg when she was twelve enhanced her already deep interest in the Civil War. She attended Duquesne University in Pittsburgh, and entered the Army Nurse Corps upon graduation.  Serving during the Vietnam War era, she cared for the bodies and spirits of soldiers and veterans, including repatriated POWs and MIAs. Now living in Colorado, she is a member of a Disaster Medical Assistance Team, and has been deployed to disaster areas around the country. True Colors is partly based on her military and nursing experiences as well as extensive research. She also authored The Arrow That Flieth By Day, a historical love story set in 1860s Colorado, and Refining Fires, a uniquely written love story that was released in July, 2010. Erin invites you to visit her “virtual fireside” at www.erinrainwater.com.

Friday, January 28, 2011

The Face Behind the Mask: Part 3/5

We're continuing our five part Friday January/February series with certified nurse anesthetist Kimberly Zweygardt. By the way, happy Nurse Anesthetists Week Kim!

So far, we’ve met the characters in the OR and discussed the setting. Today, let’s talk about things that could go wrong including anesthesia complications.

Andartur/Photobucket
We’ve all read about wrong patient or wrong operation or surgeons operating on the opposite leg, hip, etc. Safegaurds, like the time out, are designed to prevent this, but what if it increases plot tension?
 Also, the OR is its own little world—only staff and patients allowed, but there was a case where someone impersonated a doctor. What did the nurse say when she found out he wasn’t a real surgeon? “I couldn’t tell. He was wearing a mask!” In a large teaching hospital there are students of all types and the OR gets much more crowded. It would be possible for someone to sneak in with mayhem on their mind, although safegaurds like doors to the dressing rooms with keypad entries have become common.
The OR is a very busy place and patient care comes first. As the case ends and the patient wakes up, there is lots of hub bub.My concern is if my patient is pain free and breathing before taking them to the PACU (Post Anesthesia Care Unit), not about the drugs which locked up unless being used. While I’m gone, the room is “turned over” (cleaned and readied for the next case). Nurses, scrub technicians and housekeeping are in and out. In some OR’s an anesthesia tech cleans and restocks the anesthesia supplies, changing the mask and breathing circuit on the anesthesia machine so that when I return, all I have to do is draw up drugs for the next patient.
Due to the nature of the OR, the anesthesia cart is unlocked so that the tech can restock drugs and supplies. What would happen if someone had murder on their mind?
Drug companies sometimes use the same labels for different drugs. For example, Drug A is in a 2cc vial and slows down the heart. The label is maroon and the vial has a maroon cap. It is clearly labeled as Drug A. Drug B also is a 2 cc vial with a maroon label and has a maroon cap but Drug B increases the blood pressure. What happens if the pharmacist sends the wrong drug because he recognized the colored label and grabbed it? Or if both drugs are in the anesthesia cart, but one vial gets put in the wrong drawer along with vials that look identical? Or the patients blood pressure is dangerously low and in my hurry, I grab the wrong drug and slow down the heart causing the blood pressure to plummet even lower? What if it wasn’t an accident?
For your comfort, practitioners are know about “look alike” drug vials and take special precautions to prevent errors. Don’t be afraid if having surgery, but what fun would that be for our characters? Remember this blog post is about getting the medical details right, not making our characters happy!

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Kimberly Zweygardt is a Christ follower, wife, mother, writer, blogger, dramatist, worship leader, Certified Registered Nurse Anesthetist, a fused glass artist and a taker of naps. Her writings have been featured in Rural Roads Magazine, The Rocking Chair Reader, and Chicken Soup for the Soul Healthy Living Series on Heart Disease. She is the author of Stories From the Well and Ashes to Beauty, The Real Cinderella Story and was featured in Stories of Remarkable Women of Faith. She lives in Northwest Kansas with her husband where their nest is empty but their lives are full. For more information: www.kimzweygardt.com

Wednesday, January 26, 2011

Signs vs. Symptoms

Sometimes as a nurse, I wish I could live in a Star Trek episode and pull out my tricorder, grabbing my assessment with a quick hover of the device over my patient. Those crafty gadgets could tell you everything about your patient. Unfortunately, we aren't blessed with these yet so it's good academia to know the difference between a sign and a symptom when writing a medical scene.

Any guesses as to what the difference is?

A symptom is something subjective felt by the patient and told to the nurse or physician. It is not measurable. For instance, a person coming in with abdominal pain might say: "I feel like I'm going to throw-up. It feels like someone is stabbing me in the gut with a knife!" All of these things the patient describes are symptoms. We can't measure them and we only know they're present because the patient tells us so.

A sign in the medical sense is something we can measure. Let's take the same patient from above. He has relayed to the medical staff that he is having some pain. Some signs of pain are sweating (diaphoresis), increased heart rate (tachycardia), increased blood pressure (hypertension). These we can assess and measure.

Now to throw a wrench into my definition. At times, we try to measure symptoms like pain. This is why we have pain scales. A patient states they're having pain. The nurse replies: "Sir, on a scale of 0-10, zero being no pain and ten being the worst pain you've ever had in your entire life, how bad is your pain?" We attempt to measure but it is still the patient's subjective experience.



Here's a very common ER set-up that can increase conflict between the patient and the medical staff.

A patient presents to the ED with complaint of a headache. There are several patients to be triaged and the person takes a seat in the waiting room. He strikes up conversation with another family. After that, he puts his ear buds in and is texting on his phone. I can see that this patient has signed in and what his complaint is on my computer screen. I decide, based on his complaint and his behavior in the waiting room, he's okay to wait for me to triage the other patients.

In triage, he continues to complain of a headache. He is warm and dry. Sits comfortably. Heart rate and blood pressure are normal. I ask him to rate his pain. "It's 15/10. This is the worst headache of my entire life!!"

See the conflict? Do you believe this patient is in pain? If yes, why? If no, why?

Monday, January 24, 2011

Civil War Medicine: Part 3/4

 

Civil War Medicine, Part 3

Conditions and treatments

  
Unlike today, the majority of soldier deaths during the Civil War were attributed to disease. Unsanitary and close-quarter living conditions in the camps led to outbreaks of dysentery, typhoid, measles, smallpox, chicken pox, throat distemper (diphtheria), and other diseases. Scurvy and other nutritional disorders were prevalent, as was typhus from lice and fleas. Mosquito-borne illnesses such as yellow fever and “ague” (malaria) also posed a threat, although they were believed due to “miasmic vapors” from stagnant waters. Minor wounds such as from a splinter, a scratched mosquito bite or the rub of a boot could become infected and ultimately lead to septicemia and death. Lacking scientific knowledge regarding the causes of disease, physicians depended on a few standard remedies, such as quinine, calomel, ipecac and opium to cure most symptoms. Mercury was used to treat venereal disease, although it only cleared the symptoms and was not a cure. Nitric acid was poured on open wounds to kill infection. It also seared the flesh.


distopicmodpics/Photobucket

The physiology of some conditions, such as the gastrointestinal system, was surprisingly well known back then. The digestive process was understood, as well as the length of time for various foods to be digested. Much of this knowledge came from Dr. William Beaumont’s experiments and studies, including the observation of an open stomach wound in a man who’d been shot. Gastrostomy tubes were used for feeding patients with such wounds, and drains were placed to remove infectious drainage and gastric juices. Cardiopulmonary-wise, physicians used stethoscopes to discern crepitant rales and rhonchi, heart murmurs and friction rubs. They used percussion techniques in the physical exam to appreciate dullness and diminished resonance of the chest and abdomen. Mercury thermometers were available but rarely used. Fever was considered a disease, and temperatures were taken only to investigate unusual maladies or those of special concern. Doctors then were faced with some of the same frustrations of today: addicts pilfering drugs and alcohol, and well-intentioned family members offering food to patients with serious stomach and intestinal ailments and wounds.

Wounds, of course, were the other consideration in this war of inconceivable casualties. As bullet manufacturing changed during the war so did the wounds they left. The small- caliber round balls shot from a smooth bore musket often produced a different type of wound than the newer, faster velocity, conical-shaped slugs later produced. All had the capacity to incur catastrophic injuries beyond repair. In battlefront hospitals, there were few alternatives to amputation of limb wounds, and an experienced surgeon could perform the procedure in under ten minutes. Later in the war some surgeons experimented with blood vessel resection, but amputation remained far more common. Soldiers with head and chest wounds were given a poor prognosis, and often not considered treatable. Bullet wounds were the most common by far, but those from canister, cannonballs, shells, sword and saber had to be reckoned with as well.

It was considered routine that combat wounds become infected. Pus was considered “laudable” because the body was discharging poisons, a necessary adjunct to proper healing. In the rare instances pus did not appear, it was called “union by first intention” and considered an utter mystery. Yet there were five types of infections acknowledged as abnormal. A triad of infections referred to as “hospitalism” included gangrene, erysipelas (a skin infection we now know is caused by strep), and pyemia (septicemia, or “blood poisoning.”) The mortality rate from these hospital-acquired infections reached ninety-five per cent. The survivor of a “routine” infection often became the victim of osteomyelitis, a chronic bone infection, and was doomed to a slow and painful death from a festering wound where entire sections of bone would be eaten away. Tetanus was present, though less common than other diseases, because most battles were fought on virgin soil unfouled by the manure that carries the tetanus spores.

Wet dressings could be applied utilizing a siphoning technique. One end of a strip of cotton or linen was placed in a container of water suspended over a wound. The other end of the material hung just above the wound but below the level of the water, thus providing a continuous drip. The nurse was freed up from having to return for frequent remoistening of the bandage. Oilcloths were placed to catch the excess water and drain it into a vessel on the floor.

With flies rampant, so were their eggs, or maggots. Although the critters caused no pain, female nurses were disgusted by them and their wiggling bothered the wounded men. Yet some discerning surgeons detected that wounds infested by maggots healed more rapidly, and that the little vermin actually cleansed wounds, digesting and removing dead tissue while leaving healthy tissue uninjured. Rats reportedly tendered similar results. Some modern day physicians have accepted maggot therapy as useful for debridement, although I’ve yet to see where rat therapy has become part of standard treatment.

Without the benefit of x-ray equipment, sometimes the only way to hit upon the location of a bullet was to take “soundings.” In my novel True Colors Cassie Golden, who at this point thinks she’s seen everything, watches in awe as a Confederate surgeon inserts a porcelain-tipped probe into a wound and taps it against various obstacles. She observes that the sound of tapping bone versus lead is distinguishable. Additionally, when the doctor rubs the white-tipped probe against lead it comes out streaked with gray—a sign it has detected its quarry. Like all nurses, she realizes that the learning process is never over.

Next Monday: Were Civil War practitioners of medicine hapless, or heroic?

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Erin Rainwater is a Pennsylvania native whose trip to Gettysburg when she was twelve enhanced her already deep interest in the Civil War. She attended Duquesne University in Pittsburgh, and entered the Army Nurse Corps upon graduation.  Serving during the Vietnam War era, she cared for the bodies and spirits of soldiers and veterans, including repatriated POWs and MIAs. Now living in Colorado, she is a member of a Disaster Medical Assistance Team, and has been deployed to disaster areas around the country. True Colors is partly based on her military and nursing experiences as well as extensive research. She also authored The Arrow That Flieth By Day, a historical love story set in 1860s Colorado, and Refining Fires, a uniquely written love story that was released in July, 2010. Erin invites you to visit her “virtual fireside” at http://www.erinrainwater.com/.

Friday, January 21, 2011

The Face Behind the Mask: Part 2/5

We're continuing our five part Friday series with certified nurse anesthetist Kimberly Zweygardt.

Last post we discussed who is in the OR. Today let’s talk about the OR setting then discuss the anesthetic.
The OR is a cold, sterile, hard surface, brightly lit environment that is all about the task instead of comfort. Cabinets hold supplies, the operating room bed is called a table, Mayo stands hold instruments for immediate use during the operation and stainless steel wheeled tables hold extra instruments and supplies. IV poles,  wheeled chairs/stools and the anesthesia machine and anesthesia cart complete the setting. 
ejburkhardt/Photobucket

When a patient comes in, the staff does a “time out.” The circulating nurse, the surgeon and anesthetist all say aloud that it is the correct patient and procedure. It sounds like this, “This is Mrs. Harriet Smith and she’s having cataract surgery on her left eye.”  Once done, the staff swings into action, the circulator “prepping” the surgical site (washing it off with a solution to kill the germs) while the scrub nurse prepares the instruments after “gowning and gloving” (putting on sterile gown and gloves). Meanwhile, the surgeon “scrubs” meaning washing his hands at the sink outside the room. When he is done, he’ll enter the room to get gowned and gloved. Before all this is happens, I’ve started my care of the patient.
I meet the patient before this to fill out a health history specific to anesthesia. Are they NPO (Have they had anything to eat or drink after midnight)? Do they have allergies? Have they ever had an anesthetic and if so, any complications? Has anyone in their family ever had complications with anesthesia? Then I ask about medications and other health problems  so I can choose the best anesthetic. But an even bigger job is reassuring them that I am there to take care of them.
When they come to the OR, I attach monitors—EKG heart monitor, blood pressure cuff, and pulse oximetry (a small monitor that fits on the finger to measure the oxygen levels in the blood). Once the monitors are on, I give medicines for the  “induction” of anesthesia. As the patient goes to sleep, they are breathing oxygen through a face mask. Drugs include the induction agent (most likely Propofol), narcotics (Fentanyl most common), an amnestic (Versed which provides amnesia), plus a muscle relaxant (Anectine)that paralyzes the muscles.  When asleep, the breathing tube is placed using a laryngoscope that allows me to visualize the vocal chords. Then the anesthetic gas is turned on.
I am with the patient through the whole operation, watching monitors, giving medications and making adjustments.  At the end, I reverse the muscle relaxants, turn off the anesthetic gas, and begin the “emergence” process waking the patient up.
Now, that’s the norm but we’re writer’s where normal is boring! Next post I’ll let you in on all the things that can go wrong!

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Kimberly Zweygardt is a Christ follower, wife, mother, writer, blogger, dramatist, worship leader, Certified Registered Nurse Anesthetist, a fused glass artist and a taker of naps. Her writings have been featured in Rural Roads Magazine, The Rocking Chair Reader, and Chicken Soup for the Soul Healthy Living Series on Heart Disease. She is the author of Stories From the Well and Ashes to Beauty, The Real Cinderella Story and was featured in Stories of Remarkable Women of Faith. She lives in Northwest Kansas with her husband where their nest is empty but their lives are full. For more information: www.kimzweygardt.com

Wednesday, January 19, 2011

Traumatic Brain Injuries: Treatment

Last Wednesday we looked at the basics of severe traumatic brain injury (TBI). Remember, the basis of treating TBI is manipulation of the three components within the skull: the brain, the blood, or the cerebrospinal fluid (CSF).

1. Manipulating Brain Tissue:

Removing brain tissue is an option and may be done to tissue that has died. Recovery of the patient is dramatically influenced by what part of the brain was removed.

Another management strategy is to put the brain at rest by placing the patient in a medically induced coma. You may have heard about this in relation to Gabrielle Gifford's care. Medication is used to heavily sedate the patient. Typically, the patient is on continuous EEG monitoring to ensure a minimal amount of brain activity is present. The purpose of the coma is to reduce the metabolic demands of the brain in hopes of keeping swelling down and allowing the brain time to heal.

Additionally, a diuretic, typically Mannitol, can be given to draw water out of swollen brain cells.



shrhome/PhotoBucket

2. Manipulating Blood Flow:

This can entail a couple of areas. Remove blood that has collected in the brain. Sometimes when the brain is injured, blood vessels within the brain are ripped open. Two types of bleeding can occur between the brain and the skull: a subdural or epidural hematoma. A subdural hematoma occurs from veins. An epidural hematoma occurs from an artery. Depending on the size of the hematoma, a neurosurgeon may choose to operate and remove it. Sometimes bleeding occurs within brain tissue. This type of bleeding can be small and more diffuse. Although a risk for the patient it may not be an option to surgically remove it.

Another way to manipulate blood flow is to manipulate the size of the blood vessels inside the patient's head. This can be done by increasing the rate of the patient's breathing on the ventilator thereby decreasing their blood level of carbon dioxide. When this level is lower, the blood vessels inside the patient's brain shrink in diameter. This therapy is controversial and if done, only a mild drop in carbon dioxide levels is the goal.

Lastly, the blood pressure can be manipulated. A certain blood pressure or blood flow to the brain must be maintained in order to keep the brain alive. This is called the cerebral perfusion pressure (CPP) and is calculated by using the patient's blood pressure and their intracranial pressure (ICP). Reducing the blood pressure is an option but you must maintain the cerebral perfusion pressure as well. This can be a challenging balancing act.

3. Manipulating CSF:

A drain is placed to remove excess cerebrospinal fluid.

4. Removing a portion of the skull.

I know, this isn't one of three but it is a viable option for management of brain swelling. A portion of the skull is removed (hemicraniectomy) to allow the brain room to swell. The portion of the skull that is removed is preserved by freezing so that is can be re-attached at a later point once the swelling has eased.

Have you had a character in your novel with a traumatic brain injury? If so, what type and why did you choose it?

Monday, January 17, 2011

Civil War Medicine: Part 2/4

We're continuing our four part Monday series with Erin Rainwater and her research into Civil War Medicine.

Civil War Medicine, Part 2

Changes in delivery of medical care resulting from the war


When you look at the casualties wrought by the Civil War it is mind-boggling. The Battle of Antietam in Maryland was the single bloodiest day of the war. There were over 20,000 American casualties in a single day (North and South combined). The Battle of Gettysburg was fought over three days, and 51,000 men were killed, wounded or missing. In all, more than 620,000 men died during the four-year conflict. Over half perished from disease, not battle wounds. These numbers are inconceivable, both in terms of lives lost and in the challenge of delivering medical care in a day prior to asepsis (germ-free), antibiotics, and helicopter aerovacs. As a result of the enormous casualties, many of whom were brought into nearby towns where churches, hotels, barns and even citizens’ homes were requisitioned by the armies and made into makeshift hospitals, a new system of medical care delivery was born of necessity.


barrington_hyde/Photobucket
Both governments ordered the swift construction of general hospitals to treat the injured and ill. Additionally, frontline hospitals were born of necessity. Initially, the ambulance service was maintained and run by the Quartermaster Corps. Around 1862, the medical director of the Union army, Jonathan Letterman (for whom the Army hospital in San Francisco was named) developed a system whereby ambulances and trained attendants were assigned to and moved with a division. This provided for more immediate collection of the wounded from the battlefield and transport to dressing stations and on to field hospitals. The current system of rapid response and ambulance conveyance was conceived due to the necessities brought on by the Civil War. It is interesting to note that casualties from both sides were treated at the frontline hospitals.
 
When (unsterile) silk, cotton or catgut ligatures were at a premium, horse hair was boiled to soften the texture to make it pliable for use as suture material. It was noted by some that the infection rate dropped significantly when this was used. The same was true when a lack of reusable sponges led to the utilization of one-time use rags for cleansing wounds. Applying iodine to wounds and wiping instruments with chlorine between surgeries brought similar results, but without scientific data to prove a correlation, some physicians saw no sense in these procedures.

The surgeon general remained opposed to the use of civilians and women in the hospitals, but the lack of males to perform the required duties forced the issue. Dorothea Dix, highly respected as a crusader for improving conditions in prisons and hospital for the mentally ill, managed to convince skeptical military and government officials that certain women were capable of dealing with what the war did to men. With the news of her appointment as Superintendent of Women Nurses in June, 1861 came torrents of applications from women offering their services. Working for no pay, Miss Dix personally looked after the well-being of the female nurses she hired as well as the soldiers to whom they ministered. However, in her attempt to weed out those merely looking for a husband, she would only hire women over thirty or married, strong, and plain of face and dress. Some hospitals’ chief surgeons rejected the hiring authority given Miss Dix, and in a show of defiance, refused to accept her nurses on their wards. It took a literal Act of Congress to allow the surgeons to bypass her authority and hire nurses on their own. This is what happens to the heroine in my novel, True Colors, who is considered unacceptable by Miss Dix because she is under thirty, unmarried, and not so plain. Disappointed yet undaunted, Cassie follows in the footsteps of many of her fellow rejects and marches straightway to an Army hospital and applies directly to the surgeon-in-charge. She is fortunate in that this doctor had worked alongside British Army surgeons in the Crimean War a decade earlier, and was appreciative of the role of female nurses. He hires her on the spot.

The significance of the contribution of women nurses during this conflict should not be understated. Rather than being seen as mere helpers of the main players—interesting but insubstantial—available evidence indicates their activities had important ramifications in both the immediate medical sense and the broader social sense. Truly they were the forerunners of female nurses of our generation.

Next Monday: War-related medical and surgical conditions and treatments.

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Erin Rainwater is a Pennsylvania native whose trip to Gettysburg when she was twelve enhanced her already deep interest in the Civil War. She attended Duquesne University in Pittsburgh, and entered the Army Nurse Corps upon graduation.  Serving during the Vietnam War era, she cared for the bodies and spirits of soldiers and veterans, including repatriated POWs and MIAs. Now living in Colorado, she is a member of a Disaster Medical Assistance Team, and has been deployed to disaster areas around the country. True Colors is partly based on her military and nursing experiences as well as extensive research. She also authored The Arrow That Flieth By Day, a historical love story set in 1860s Colorado, and Refining Fires, a uniquely written love story that was released in July, 2010. Erin invites you to visit her “virtual fireside” at www.erinrainwater.com.


Friday, January 14, 2011

The Face Behind the Mask: Part 1/5

Redwood's Medical Edge is happy to host certified nurse anesthetist Kimberly Zweygardt for the next five Fridays. She will be blogging about how to make those OR scenes realistic.



If you have a profession besides writing, doesn’t it bug you when someone doesn’t get it right? It may be something small, but you wonder, “Why didn’t they do some research?”  With the Internet, it is easier than ever to find information, but if it is a hidden profession like my own, there might not be much info for you to glean. Today I want to share with you, The Face Behind the Mask or The Life and Times of a Certified Registered Nurse Anesthetist (CRNA). The operating room is my world, so let’s begin there.
A CRNA is an advanced practice nurse that specializes in anesthesia. CRNA’s were the first anesthesia specialists beginning in the late 1800’s. Anesthesiologists are MDs that specialize in anesthesia (it became a medical specialty after WWII), unless of course you are in great Britain where everyone is an Anaesthetist (Ah-neest’-the-tist’). Confusing, yes? Just remember, the work is the same, but the title is different. For some reason, the term  Anesthesiologist is more widely known (because it is easier to pronounce?), but since CRNAs give over 60% of the anesthesia in the US, if you write a surgery scene, you might want to consider using a CRNA as the caregiver, especially if it is a rural setting. Over 90% of the anesthesia in rural America is provided by a CRNA.
The OR is its own world. Someone has to do the operation, so there are general surgeons, trauma surgeons, orthopedic surgeons (bone), neurosurgeons (brain and nerves), cardiovascular surgeons (heart and major vessels), as well as OB/Gyn (women’s health), ENT (ear, nose and throat) and ophthalmologists (eye surgeon). If it is a large teaching hospital, there might be a medical student or surgery resident assisting the surgeon.
 A scrub nurse or surgical technician is there who hands the instruments to the doctor as well as a circulating nurse—a RN who records what happens during the operation as well as obtains any supplies needed in the room. For example, if the doctor needs more suture, the circulating nurse would open it so it remains sterile and hand it to the scrub nurse who is also sterile.
Two of man’s greatest fears are being out of control and the fear of the unknown. The OR setting speaks to both. What great plot scenarios and drama we can create by going through the double doors that lead to surgery!  Next time we’ll talk about interesting scenarios and complications concerning surgery and anesthesia. Happy plotting!

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Kimberly Zweygardt is a Christ follower, wife, mother, writer, blogger, dramatist, worship leader, Certified Registered Nurse Anesthetist, a fused glass artist and a taker of naps. Her writings have been featured in Rural Roads Magazine, The Rocking Chair Reader, and Chicken Soup for the Soul Healthy Living Series on Heart Disease. She is the author of Stories From the Well and Ashes to Beauty, The Real Cinderella Story and was featured in Stories of Remarkable Women of Faith. She lives in Northwest Kansas with her husband where their nest is empty but their lives are full. For more information: www.kimzweygardt.com


Wednesday, January 12, 2011

Traumatic Brain Injuries: A Primer

Traumatic Brain Injuries (TBI) have been the highlight of the news lately due to the attempted assassination of Arizona Congresswoman Gabrielle Giffords. Please join me in praying for full recovery of the injured victims and for the families who lost loved ones.

The brain is our most complex organ and perhaps the most difficult to help heal. The biggest challenge is its protective covering: the skull. Management of TBI typically involves manipulating the three components within the skull: the brain, the blood, or the cerebrospinal fluid (CSF). What is the purpose of each of these components? Obviously the brain is the body's supercomputer. The blood delivers oxygen and nutrients. The CSF nourishes the brain, helps remove waste products and keeps the brain buoyant.


Jayne_031/Photobucket


What happens when something is significantly injured? It swells. Think about a time you had or saw someone with a really bad sprained ankle. What happened? It blew up like a balloon. The same thing happens to the brain with a traumatic injury. It swells. Unlike the ankle, brain swelling is inhibited by the skull but the pressure inside the head continues to rise. We can measure intracranial pressure (ICP) by placing a sensor into the ventricle (a ventriculostomy).  A normal ICP is 7-15mmHg. Cerebral edema can be insidious as swelling peaks 48-72 hours post injury. A patient can initially present following commands. Then in 2-3 days, develop cerebral edema to the point of herniation and die. This is one of the reasons the news was reporting yesterday that is was a critical day in the congresswoman's care-- it was the time period for peak swelling in her brain.

What happens when a patient develops significant cerebral edema and ICP pressures skyrocket?

First bad thing: blood flow is reduced. The brain is very sensitive to blood flow and greedy for oxygen. If there is diminished blood flow, neurons (brain cells) begin to die. If there is no blood flow, the brain will die. You may have heard the term brain death. This is determined by several factors but the definitive one is by taking the patient to radiology and doing a brain flow study. Roughly, a dye is injected into the blood and x-rays are taken. If there is no blood flow, the patient is declared brain dead.

Second bad thing: brain contents shift into areas where they're not supposed to be. This is called herniation. When neurons are compressed, they don't function properly and will begin to die as well.

Next Wednesday we'll look at the common therapies to treat traumatic brain injury.

Monday, January 10, 2011

Civil War Medicine: Part 1/4

I'm pleased to host Erin Rainwater on Monday's this month as she shares her expertise concerning Civil War medicine. Welcome Erin!

Civil War Medicine, Part 1—Pre-war medical system


This year marks the Sesquicentennial (150-year anniversary) of the beginning of the Civil War. If you’ve never studied it much, I recommend you use these four commemorative years as an incentive to expand your knowledge of it. That war was a watershed time in our nation’s history like no other event before or since, in war or peacetime. It even changed the way citizens referred to their nation. From the time of the Revolution until then the country was thought of as a collection of independent states. Shelby Foote, the Civil War historian who made you feel like you were there, said that prior to the war people would say, “The United States are…” As a result of the war, it was grammatically spoken as “The United States is…” That’s what that war accomplished, Foote said. It made us an is.

There are many interesting facets regarding the standards of medical care and how it was delivered back when we were still an are. Some of what we read about seems barbaric to us now, yet American surgeons were up to international standards of medical science of the time. Furthermore, as often happens in time of war, this conflict quickly propelled physicians into the role of leaders in medical and surgical breakthroughs.

Prior to the war, cleanliness was regarded as insignificant except in respect to gross contamination by foreign matter. Surgeons operated in street clothes or donned a surgical apron. They might wipe bloody and pus-laden instruments on their aprons or a rag, but washing them wasn’t routine. Clean linens and washed hands were statistically proven to be of value but rejected as non-scientific.

Medical school in the 1860s was normally two years long. Microscopy was taught, as was the cell theory of tissue structure. Tissue samples were stained and analyzed, urinalyses and stool studies were performed. The primary anesthetics available were ether and chloroform, each having its pros and cons. Chloroform was non-flammable, which made it preferable during the war when gunpowder was lying about and bullets flying about. It was also faster acting. On the down side, it was easier to overdose a patient with chloroform, and anesthesia-related fatalities were higher. Surgeons and attendants, however, were more easily overcome by the vapors of ether while performing surgery.

At the outbreak of hostilities, there were few military physicians, fewer military hospitals, and lack of a hospital corps. Nursing and other duties were performed by soldiers temporarily assigned to hospital detail, and who were not necessarily qualified nor of upstanding character. After the fighting began, civilian doctors flooded into the military system. Others chose not to join up but worked as contract physicians. Doctors not only were required to be skilled but were expected to organize, equip, supply and administrate their hospitals. The enlisting, training and disciplining of subordinates was also in their job description.

Female nurses were rarely tolerated. They were believed to lack the physical strength to help wounded men, and especially in the South they were considered too delicate and refined to assist a rough soldier in bathing and tending to personal hygiene. It was generally conceded, however, that women were more attuned to the emotional needs of the sick and more skilled at “sanitary domestic economy.” As word of Florence Nightingale’s notable work in the Crimean War spread, women’s abilities in the field of nursing became more widely acknowledged. Some American physicians who had gone to the Crimea to assist the British came home reporting that the female nurses were undeniably competent and able to care for soldiers with war-related wounds and illnesses. It was finally becoming more seemly for females to care for male patients. Their pay, however, was half of what civilian male nurses received to care for military patients. In my novel, True Colors, Cassie Golden receives the standard pay for civilian female nurses working in a government hospital—twelve dollars a month plus meals. That is for twelve-hour shifts, usually five days per week but often more. And she was glad to have it.

Next Monday: Some of the changes wrought in the delivery of medical as a result of the astounding number of casualties in this national enigma we call the Civil War.

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Erin Rainwater is a Pennsylvania native whose trip to Gettysburg when she was twelve enhanced her already deep interest in the Civil War. She attended Duquesne University in Pittsburgh, and entered the Army Nurse Corps upon graduation.  Serving during the Vietnam War era, she cared for the bodies and spirits of soldiers and veterans, including repatriated POWs and MIAs. Now living in Colorado, she is a member of a Disaster Medical Assistance Team, and has been deployed to disaster areas around the country. True Colors is partly based on her military and nursing experiences as well as extensive research. She also authored The Arrow That Flieth By Day, a historical love story set in 1860s Colorado, and Refining Fires, a uniquely written love story that was released in July, 2010. Erin invites you to visit her “virtual fireside” at http://www.erinrainwater.com/.

Friday, January 7, 2011

Disaster Status: Part 3/3

Another Real-Life Incident

I was on-shift the night an industrial hazardous waste plant burst into flames. I obviously have all the inside information, but it won’t be released to the public, so I’m sorry to say I can’t share most of it with you. What I can say – inside the facility, stored toxic material ignited. The fire quickly grew to a plume of smoke then the entire facility erupted into a fireball with several rapid fire explosions. This swift and extreme domino of events occurred simply because the burning toxic chemicals were stored right next to oxygen cylinders, and oxygen feeds fire. You guessed it, properly stored O2 is essential. 

   

The reverse 911 system was activated – recorded messages called all nearby residents, warning them to evacuate. View the photos included here – it was an intense explosion and the burning toxic chemicals created a massive haz-mat situation. The chemicals involved in that explosion react negatively when mixed with water, so we were forced to allow the fire to burn itself out. Two days post the onset of the incident, a foam application extinguished the remaining flames.



Even though this makes for boring fiction, emergency agencies that night proved pre-planning and inter-agency training and execution results in excellent emergency incident response outcome. My crew along with many other emergency crews, successfully worked the potentially deadly incident – no loss of life and only minor exposure issues occurred. But think of the endless possible dramas that could’ve happened.

Thank you in advance for reading and for your participation and comments. If you have any questions, please do not hesitate to ask. Photos are courtesy of Apex Fire Department.



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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. A EMT and Haz-Mat Ops 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/ 


Wednesday, January 5, 2011

Disaster Status: Part 2/3

A Real-life Haz-Mat Incident

January 6, 2005 in Graniteville, South Carolina in Aiken County, a railroad engineer left his train for the night to sleep at a hotel in town. Before leaving his train, he failed to properly reline the railroad switch for mainline operations; meaning, he simply forgot to change the rails on the track. Changing the rails would’ve closed off the track where his train was parked, successfully forcing an incoming train to veer-off onto another track and pass the parked train.

In the middle of the night, an incoming train – planning to pass the town – collided with that parked train, which contained chlorine gas, sodium hydroxide, and cresol. The collision derailed both locomotives and many freight cars. The parked-train’s tank car – containing ninety tons of chlorine – ruptured, releasing sixty tons of the gas, creating a haz-mat spill, including polluting a creek.

scott007/Photobucket


A true haz-mat team – trained, experienced, and equipped for such a catastrophic event – is not located in small-town Graniteville. Only a few of Graniteville’s emergency crews are trained in haz-mat, and their training, expertise, and equipment is insufficient for an incident of this magnitude.

Inside the Avondale Mills plant near the crash site, a man in respiratory distress called 911. From a dispatcher’s viewpoint, this situation is heart-wrenching Even if rescue crews could’ve safely entered the area to extricate the man, it would’ve been pointless due to his immediate exposure to chlorine. He was suffering bronchial chlorine burns, and he died a painful death while on the phone with the 911-dispatcher. For haz-mat training purposes, I listened to that chilling 911-Call. Overwhelmed in every way, that dispatcher could only listen as this man gasped his last breaths. Understandably, she had no words of comfort to offer him. That gave me passion to become a 911-dispatcher once I’m too old to run 911-Calls on an ambulance. When that man asked the dispatcher – “Please, don’t hang up; I don’t want to be alone.” I would’ve spoken with him about his family and his passions in life in order to get him as relaxed as possible. I would’ve talked about God and offered to pray with him. Often when people suspect their death is imminent, they suddenly forget all about being atheist, agnostic, stumbling in their faith, or whatever else, and reach for God.

Due to this haz-mat incident, nine people died, 250 were treated for chlorine exposure, and 5,400 residents within a mile radius of the crash site were forced to evacuate for nearly two weeks while haz-mat teams and clean-up crews decontaminated the area.  

Think of the fictional characterization possibilities within this tragedy:

1) Plagued by guilt, the train engineer is pushed over the edge by predisposition to mental illness, and becomes a murderous psychotic (an example of a villain in one of my books). What similar characters could you develop? To be honest, though, my heart goes out to that train engineer. My greatest fear in life is making an unintentional mistake as an EMT, resulting in a patient’s death.  

2) The 911-dispatcher: For fictional purposes, let’s suppose it was this dispatcher’s first day alone (no longer training) on the job that horrible night in early 2005, and she resigned, making her first day also her last. Think about the baggage she would carry for years to come. In addition, what if she was already in a severe financial bind and now being jobless she’s in dire straits? She’d make a likable and fascinating main character.  

3) Me, the future 911-dispatcher – what if a character had aspirations to be an amazing dispatcher but fails miserably? What if he/she is unable to handle the stress of the work and is then lost in life on where to head career-wise? Another idea for a terrific main character.

Monday, January 3, 2011

Disaster Status: Part 1/3

We're going to start the New Year off with a bang. Nothing can complicate a story more than a disaster hitting the town in your novel. What would a realistic response look like from the EMS community? There's no one better to talk about disasters than an EMS professional. Dianna's back this month with a three part series on disaster response.

Worst Possible Haz-Mat Situations



In a hazardous-material situation, a small town can easily and rapidly become overwhelmed and thus unable to efficiently handle the crisis at hand due to their limited resources. Below is a list of some additional factors beyond “the town is small” that would heighten the chaos, and for writers, would create solid fictional conflict.

Scenario: Traveling at high speeds, two tanker trucks collide; both roll-over. One truck is an atmospheric pressure tank; the other is a cryogenic liquid tank.

donW23/Photobucket

Additional possible factors….

The accident occurs:
1)      Near a school during school hours
2)      Near a stadium filled with spectators and athletes/performers
3)      Near a power plant
4)      Near a hazardous waste facility
5)      Near the town’s landfill (landfills contain countless haz-mats)
6)      Near the town’s water treatment plant
7)      Near the town’s only EMS station
8)      Near the town’s only hospital
9)      Near the town’s only fire department
10)  Near the town’s only police department
11)  During rush hour traffic
12)  During a storm
13)  At 3am
14)  The closest haz-mat team is four hours away

In all of the ten “near” cases above, assume those buildings/areas are contaminated by hazardous material spills from both trucks. Haz-mats are often airborne (so air vapors), which are the most deadly simply because air vapors are invisible – they travel quickly, through most any material (including ventilation systems), and without warning; plus they’re next to impossible to contain. Sometimes an unusual cloud or smell is detected, but obviously that warning comes concurrent of the smell and/or cloud discovery, so those individuals in or near the hot zone are already exposed. Keeping safe distance from the hot zone is the only way to eliminate exposure.

Minimum safe distances depend on the chemicals of the hazardous materials present, but an example of an initial minimum safe distance is: 1,000 feet downwind, 500 feet upwind, 330 feet complete radius. Avoid downwind areas entirely and stay upwind. Clearly, continuous monitoring of wind changes is vital.   

What additional scenarios and additional factors can you think of?