Kristen Lamb

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Malpractice: Getting Medical Facts Right in Fiction

It’s Squatter’s Rights Wednesday again, and you know what that means! Well, first, it means the obligatory photo of Denny Basenji. But right after that, it means that I’m going to take the Red Pen of Wrath to a topic, and today’s topic is medicine. Specifically, medicine in fiction. Why? Because I’m tired of being jerked out of stories by medical inaccuracies. It’s the literary equivalent of having to dig for a vein…for the third time.

So, first: Denny Basenji.

This is Denny Basenji coming out of surgery last summer. He’s wondering if the patient will get peanut butter ice cream…or maybe peanut butter jello…

Okay, let’s get down to business.

If we are going to put a character in the hospital, we need to know how to do it. We also need to know what happens inside a hospital and how long people stay. We need to know what nurses can and can’t do, what doctors can and can’t do, and why our character’s friend-of-family-doctor can’t simply take charge of her care. We need to know what happens after a character goes home in terms of when they can go home, why they are allowed to go home, and what the follow up care is.

I’m not a doctor, but I play one in my books

Why listen to me? Because I’m a f*cking gold star club card holder at Massachusetts General Hospital. Here’s a list of my experience and “qualifications.”

Yours truly getting her monthly immune suppression therapy intravenously. Still smiling after two tries for the iv and three separate sticks for blood work.
  • I’ve had a kidney transplant since 2007. I’m a walking encyclopedia on infectious diseases, pharmacology, and clinics.
  • I’ve had cervical cancer. Luckily, mine was caught early and completely by surgery. But, I went with my friend Jaime to her chemo treatments – all 19 of them. I know a few things about how chemo works now.
  • I have been hospitalized for infections, accidents, near-death drug interactions.
  • I’ve been taken in ambulances, taxi cabs, and driven myself.
  • I’ve ended up in the hospital in everywhere from Portugal to New Mexico.
  • I was hospitalized for pneumonia. Wheeze, cough. Cough. Ow.
  • I’ve been hospitalized for multiple infections of various kinds as a result of having no immune system (thanks, kidney transplant!).
  • I was hospitalized for a stomach infection (that had an upper GI endoscopy involved – SO much fun).
  • I’ve had miscarriages from 6 weeks to 5 months.
  • I’ve had enough iv’s and blood draws that I could be an iv nurse. Or part-time vampire.
  • I’ve worked in hospital administration. I am surrounded by friends and family who are doctors and nurses.
  • I’ve had ultrasounds, x-rays, CAT scans, MRI’s, stress tests, bone density scans, you name it. Interventional radiology procedures like angiograms are lots of fun, too.
  • I’ve sat at the bedside of my father as he went through heart attacks, surgeries, and finally the strokes that killed him. I know what it’s like to watch someone die.
  • I know how an ICU works.
  • Blood transfusions. I’ve got a frequent customer punch card.

Basically, I am at the hospital 2-4 times every month for various reasons. Mostly outpatient appointments, but I’ve got a collection of more than 30 wristbands that tell the story of my inpatient experience. You can just call me Dr. Cait. Or Nurse Cait. Or Frankencait.

Just one teeny weeny example: how to put a character in the hospital

So…there’s a famous set of books about a color somewhere between black and white…lots of people object to the rather “adventurous” sex scenes in it. Others object to the objectification of women and power dynamics of the main relationship. Me? I object to the ham-handed handling of the protagonist’s injuries that land her in the hospital.

She’s injured. She falls unconscious. She wakes up in a hospital room with her husband’s mother – a pediatrician – helping to manage her care.

Cue the…

 

Let’s call our character “Jane,” as in Jane Doe.

Please disabuse yourselves immediately of the standard “Jane wakes up in the hospital and doesn’t remember getting there.”

It almost NEVER happens like that, and if it does, Jane will have had to have been in a horrific, life-threatening accident. It’s actually pretty rare that people lose consciousness. The body’s defense mechanisms drive us to remain conscious, or at least semi-conscious, as much as possible.

If Jane does fall unconscious, the norm is to “surface” fairly quickly. Minutes, usually. Again, do your homework about just what could cause prolonged unconsciousness – and the side effects. Jane could be facing oxygen depletion in the brain and potential brain damage. Jane could have swelling of the brain, another life-threatening condition. Jane could have sustain other neurological damage. Prolonged unconsciousness is no joke, so please stop using it as a plot device unless you  know what you’re doing.

The Emergency Room

This is going to be the way Jane goes into the hospital in 99% of situations.

In the ambulance, Jane will have a paramedic with her, taking her vitals (blood pressure, heart rate, temperature), and doing emergency stabilization if necessary:

  • Epinephrin shots to reduce allergic reactions, anaphylactic shock, angioedema, etc.
  • Morphine for pain management
  • Possible treatment for diabetic reaction
  • Defibrillation for cardiac arrest, along with emergency cardiac medication (depending on the situation)
  •  Insertion of an iv and bag of saline hookup if signs of blood loss, dehydration, low blood pressure, etc.

Forget what you see on tv about arriving via ambulance. It doesn’t happen that way. Unless you have a machete sticking out of your forehead (I saw that arrive at MGH once when I was in an ER bay myself – that was fun), there will be no running or shouting.

The paramedics will remove Jane’s gurney from the ambulance and wheel her inside. A triage nurse will be waiting, as well as a hospital registration admin. If Jane is conscious, the hospital registration admin will ask her for basic information like, has she ever been a patient here before? Does she have an insurance card with her? Name, date of birth, address, person to notify, etc.

Please note, that even if Jane is in a ton of pain, as long as she is conscious, the hospital registration admin will ask these questions. Trust me, I’ve been there before. It’s not fun to answer questions like that when you are burning up with fever or writhing in pain, but it has to be done.

Fever of 102. Sepsis (life-threatening bacterial blood infection). Missed complete organ failure by just a few hours. Bored out of my mind waiting for further test results. What to do? Play Candy Crush and take selfies. Because you can be near death, in the ER, and FULLY AWAKE.

The triage nurse in the meantime will be getting the paperwork and rundown from the paramedic. This will be happening calmly and quickly. Once Jane is done with the hospital registration admin, the triage nurse takes over.

Treatment in the ER

The triage nurse takes Jane from the arrival area into the treatment bay area. In an ideal world, Jane is given a curtained-off bay right away. In the real world, Jane might be placed “in orbit,” which means that her gurney will be lined up against the wall with other patients on gurneys, waiting for a bay to open up. Jane will receive the same level of care, just not in a bay.

Once Jane is in a bay, the triage nurse will return to her work at the triage station, and Jane’s primary nurse will come to take care of her. Jane’s primary nurse will also probably have an assistant – a patient care assistant or PCA.

Whether able to do it herself or with the help of the nurse and PCA, Jane will be changed into a hospital gown, and her clothes and personal effects put into a big plastic bag labeled with a sticker printed with all of her information and also the same barcode that is on her hospital band. Oh yeah, almost all hospitals now have barcodes on hospital bands now. These are scanned when medication is administered.

Jane’s primary nurse will ask for her version of the story of what happened to bring her to the ER. The nurse will also ask Jane about any medications she currently takes, as well as any allergies she has. While this is going on, the nurse will be putting on a blood pressure cuff (absolutely always), electrodes for echocardiograms (depending on the situation), taking her temperature (absolutely always).

Jane will be asked to rate her pain level from 1-10, with 10 being the worst.

Now, here comes the kicker. The nurse leaves Jane now. That’s right, unless Jane is actively bleeding to death or having cardiac arrest or something similar, Jane is left alone with a call button. This is because the nurse now goes and enters all of her information into the hospital records system, which then feeds it to the assigned doctor.

Ah, finally, the entrance of the doctor…sorta.

Jane will not meet the doctor just yet. The doctor will review Jane’s situation and order bloodwork, maybe a urine test, and possibly other tests like an ultrasound or x-ray. The doctor will also “write an order” for pain medication if needed. The doctor will also write an order for any anti-nausea medication or fever-reducing meds like Tylenol.

Once the orders have been entered into the system, two things could happen. One, the ER has its own mini-pharmacy with basic medications (anti-nausea drugs, Tylenol, certain types of pain medications), and the nurse can unlock the pharmacy cabinet with her ID badge. Or, the hospital pharmacy receives the orders on their computers, and processes all the requests, sending a delivery person to bring the meds to the ER.

This whole process generally takes anywhere from 20 minutes up to an hour and a half. Yup. Jane just has to cool her heels and suffer through this time. It’s not fun, but it’s necessary.

The nurse returns to Jane, drawing blood (which is a whole other post), and administering whatever medications the doctor has ordered. If Jane has to have an x-ray or ultrasound, a transport person will arrive and wheel her in her gurney off to the imaging area where she will be placed in a waiting area until the next available imaging tech is ready for her.

There will be another post about X-rays, ultrasounds, MRI’s and CAT scans, and interventional radiology, but for now, you just need to know the basic tests generally don’t take too long, and they can all be done with Jane either still in the gurney if she’s unable to move, or with Jane standing up.

Jane is returned to the waiting area in imaging until a transport person arrives to take her back to her bay.

The nurse will check on Jane, run her vitals again (blood pressure, heart rate, and temperature), assess her pain, and make sure Jane is as comfortable as she can be (did I mention the WARM blankets that they have available for patients?). There is no food or drink until at least initial results are back.

Denny Basenji strenuously objects to the no food or drink policy.

Then, it’s another waiting period for the results of the bloodwork and the other imaging tests to come back. Once it’s all back and the doctor actually has a minute to review everything, Jane will finally get a chance to meet the doctor.

The doctor will knock and enter, introducing himself (could be a herself, but for the same of less confusion with pronouns, I’ll go with a Dr. Taylor McHotterson), and asking Jane to tell him the story of how she came to be in the ER. Yes, it’s in her records, but every new nurse and doctor she meets from here on out will request her story. It’s protocol.

The doctor will definitely listen to her heart and her lungs, and potentially check her joints for swelling, as well as doing a hands-on exam of her belly to check her organs.

Then, Dr. McHotterson will explain so far what they have learned about Jane’s condition. Depending on what is wrong, this could result in more tests, starting intravenous drug treatment, emergency surgery (and no, they’re not going to run down the hall with her down on the gurney unless she is literally dying), admission to inpatient treatment, or discharge. Any or all of this basically requires Jane to do…nothing. Except wait. And try to sleep. If she going to be admitted, the staff has to contact the correct ward, find out if there are any beds available, and if not, when they might be or where else they would have to put her. All of this could take anywhere from an hour (record-breaking speed) to 12-14 hours, with an average of somewhere between 3-6 hours of waiting.

Do we really need to know all this?

Well, yes. We might not have to describe everything in agonizing detail like I have done above, but knowing the process will make the Jane’s inpatient scene more realistic. Having a basic grasp of the facts about whatever injury or condition our characters have helps us create more detailed, immediate, and immersive experiences for the reader.

Still, it can be daunting, trying to figure out what we need to know and how much we need to know medically, and then learning what we need to leave out in terms of writing craft. The good news is that with a little thinking, a little logic, Dr. Google, and MY CLASS, you can learn not just how to figure out your character’s medical care, but how to use it to up the tension, pacing, and conflict in your story!

 

Instructor: Cait Reynolds

Price: $40.00 USD

Where: W.A.N.A. Digital Classroom

When: Wednesday, August 16, 2017. 7:00-9:00 p.m. EST

From fainting to family doctors in the OR, fiction today is full of medical malfeasance. Watching George Clooney or Ellen Pompeo run through the ER yelling “Stat!” may seem like just what the doctor ordered to up dramatic tension in fiction, it’s more likely to be 20cc of the wrong medicine.

Nothing shatters the fragile suspension of disbelief for the reader like inaccuracies, whether it’s historical, behavioral…or medical. Whether your character is injured in a car crash, poisoned, knocked unconscious, or comes down with the flu, it’s critical to get the details right.

Like a first responder, this class is on the scene to help you resuscitate realism in your medical scenes. This will be a crash course on how to avoid making the most common mistakes and how to get the facts for whatever you inflict on your characters in the future.

This class will cover:

  • From ambulance to admission, how your character actually ends up in the hospital;
  • What happens while your character is inpatient (from blood work and imaging, to iv’s – especially iv’s!!! – and hospital food);
  • The different kinds of medications, treatments, and timelines for characters to recover from a wide range of illnesses and injuries;
  • The truth about knocking your character unconscious: how, how long, and what the short- and long-term consequences are;
  • From birth to death, clinical procedures and protocols;
  • How to research medical information and get it right in your descriptions.

At the end of the class, we will have an open Q&A sessions where you can ask about medical scenarios for your characters.

A recording of this class is also included with purchase.

About the Instructor:

Cait Reynolds is a USA Today Bestselling Author and lives in the Boston area with her husband and four-legged fur child. She discovered her passion for writing early and has bugged her family and friends with it ever since. When she isn’t cooking, running, rock climbing, or enjoying the rooftop deck that brings her closer to the stars, she writes. http://caitreynolds.com

 

For the month of AUGUST, for everyone who leaves a comment, I will put your name in a hat. If you comment and link back to my blog on your blog, you get your name in the hat twice. What do you win? The unvarnished truth from yours truly.

I will pick a winner once a month and it will be a critique of the first 20 pages of your novel, or your query letter, or your synopsis (5 pages or less).

****And MAKE SURE to check out the NEW CLASSES classes below including the final class I will teach before taking off for NEW ZEALAND! I’m keynoting there for the Romance Writers of New Zealand, which while SUPER COOL….I’d be lying if I didn’t say the trip wasn’t making me more than a tad nervous.

All classes come with a FREE recording!

We’ve added in classes on erotica/high heat romance, fantasy, how to write strong female characters and MORE! Classes with me, with USA Today Best-Selling Author Cait Reynolds and award-winning author and journalist Lisa-Hall Wilson. So click on a tile and sign up!

OMG! Like, How to Write On Fleek YA. $40.00 USD. Wednesday, August 23, 2017. 7:00-9:00 p.m. EST. Click the image to register!
How to Dominate Your Sex Scenes (No Safe Words Here). $45.00 USD. Wednesday, August 30, 2017. 7:00-9:00 p.m. EST. Click the image to register!
Class Title: Beyond Lipstick and Swords: Creating Strong Female Characters. $40.00 USD. Saturday, September 9, 2017. 2:00-4:00 p.m. EST. Click the image to register!

22 thoughts on “Malpractice: Getting Medical Facts Right in Fiction”

  1. Sophie KiskerSophie Kisker

    Oh, God bless you! I’ve been a nurse for 28 years, and generally refuse to read romance novels with medical scenes because of how bad they are. One thing you didn’t mention – and I hope you never have to experience this – is the procedure to collect evidence after a rape. It’s meticulous, takes hours, is invasive, and the vitcim has to leave her clothes behind. Please encourage people to research this topic as well before they write about it!
    I hope your class fills up full. I’m going to link to it on my FB page.

  2. YasmineYasmine

    I’d forgotten how bored I was in the ER after a auto accident. I didn’t even notice the rising bruises on my body from where my seatbelt had restrained me. The doctor pointed it out and scheduled me for every freaking test. I was concerned I’d cracked a few bones in my foot – which by the way they said weren’t broken, but prior experience told me that a couple of days later it would show up. I walked in at night, didn’t get out until 8am the next morning. In the bay next to me was a woman ranting both in English and a foreign language. I knew when shifts changed and that there was a 24/7 Starbucks in the hospital right down the hall. I was scared and bored. Thankfully I was okay. And I bought a Venti coffee for my cab ride home.

  3. Laurel NewberryLaurel Newberry

    Wonderful information, and well presented. As someone who has experience in medical procedures and interventions – as patient, family member of patients, and as a physician’s spouse – I have a low threshold for inaccuracy in medical drama. Classes that help authors find correct information and write realistic scenes are pure gold. I can think of nearly a dozen good stories I’ve read that would have been great stories if only they’d had a firm grasp of medical reality. Thank you for speaking up!

  4. Mary Rebecca JohnsonMary Rebecca Johnson

    Cait, God bless you for being an ER/ hospital victim so many times, and for being a stickler for correct medical information. I worked in clinical laboratories and physician labs for more than 30 years (as well as a 3-year hitch as a CLIA laboratory surveyor for the state of South Carolina), and nothing jerks my chain worse than for someone to glibly report that their character received the wrong unit of blood and then jumped up and whupped a bad guy. SOOoooo not happening. — It’s all too easy for writers to either gloss over medical scenes or totally screw them up. Perhaps they don’t want to do the research. Or maybe it’s because they think the more drama, the better–the screaming ride to the emergency room, doctors yelling “CLEAR!!” before they shock the patient who came in with a fractured toe and then just happened to have a heart attack, or lab reports coming back with a complete killer bacterial identification from just a Gram stain. Most of medical treatment is technical and boring, but it needs to be correct.

  5. Brian PopeBrian Pope

    Hello, Cait.
    As I read through your list of medical experiences, I thought I was feeling a reasonable amount of empathy. Then I got to your mention of the miscarriages, and I choked up. I’m so sorry for your losses. God bless you, dear.

  6. Deborah MakariosDeborah Makarios

    Dangabit, woman, I’m not that photogenic even when I’m in perfect health! (How does she do that?)
    I once asked a doctor if it was actually possible to kill someone with the old inject-air-into-a-vein trick. He said yes, but if you want to be certain of killing them, you need a syringe so big they’ll probably die of terror at the mere sight of it. Something around 100cc, in fact!

  7. Elizabeth DrakeElizabeth Drake

    Deepest sympathies to you on your medical struggles.

    I appreciate you sharing this. I don’t watch ER or Grey’s Anatomy or any other of these medical shows partially because my husband works in a hospital. I remember we were watching some episode and they were talking about how rare something was and impossible to cure.

    DH rolled his eyes and said they’d had a medical conference on that two weeks ago. Yeah, it was somewhat rare, but there were ways to treat it and they doctors were discussing treatment options for an unusual case that hadn’t responded to conventional treatment.

    I turned the show off. Haven’t put on a medical drama since. 🙂

  8. Maureen HowardMaureen Howard

    Hi Cait, I really enjoyed reading this.
    I am an Australian GP and also a writer, as is my sister, and we always cringe at the unrealistic hospital/ER shows where everyone is running around shouting orders and rushing form patient to patient giving haphazard treatment etc. If they did that all the time they would be too exhausted to work, they’d make a lot of mistakes and either they or the patients would drop dead.
    My sister and I always find errors in TV shows. There is a good retro Aussie drama show called Love Child, about unmarried mothers in the 60s and early 70s. It is quite realistic in most aspects eg fashion, music, treatment of girls etc.
    But I got annoyed when they started talking about doing urine pregnancy tests, which I knew were not done then.
    Another episode showed them doing an obstetric ultrasound, in 1972. I knew that we did not use ultrasound here till 1976, mainly because I trained in the hospital where it was first introduced, and also because I had my son in 1973, in the same hospital, and we had not heard of ultrasound then, apart from in experimental use. There is another popular TV show in which they were talking about oral Sabin (polio) vaccine being used, in 1960, and I knew it did not arrive in Australia till 1966!
    Writers need to know that if they make errors, some of which are glaring errors of fact, a reader/viewer will easily spot the mistake. I suspect some writers are very young, and do not do their research correctly. We recently judged a short memoir writing competition, and found that an entry we thought would come second had an error of fact, which we only noticed on the second reading. However we realised it would stand out when read aloud at the presentation day, so it was not placed.
    I’m sorry to hear you’ve had such an awful health experience, and hope things are improving for you. Your knowledge of hospitals and medical procedures is spot on!

  9. kim alexanderkim alexander

    Nice work as always! One thing that grinds my gears is using asthma as a plot point. If you have asthma that’s serious enough for it to BECOME a plot point, you are almost certainly on maintenance inhalers, and you carry a rescue inhaler with you at all times which you will rarely need. This is particularly infuriating when the subject is a child. (The worst I can think of off the top of my head was the movie Signs.) (If your plot is set pre-80’s ignore what I just said, the meds were revolutionized at that time.)

  10. excessivelyperkyexcessivelyperky

    I read PDR’s for fun drug interactions to make my characters suffer. And I have to say yay for the Warm blankets (they have them at dialysis clinics, too, where my husband goes). I once spent an instructive hour at a military base ER (nosebleed caused by a bad softball hop wouldn’t stop bleeding) listening to an MP discuss just what the alcohol blood test showed to the car wreck person on the other side of the thin partition (I take my entertainment when I can), and glad it wasn’t me. I also give people idiosyncratic drug reactions, having learned that my mother-in-law’s metabolism interpreted Valium as speed. I’m horrible to my fantasy characters, too–let’s see, there’s the burn victim who ended up addicted to his pain meds, the ruling lady with exciting OB/GYN problems, the young hero dealing with mild neural deficits from when he fell off the horse and whanged his head, the mentor with the serious drinking problem…God, I love it.

  11. R CootsR Coots

    Ah, good info. My mom has been a nurse (ER) mainly, for thirty years now and some of the knowledge has come over by osmosis. Some hasn’t. One thing to mention though, is things might be different in a small town hospital. Ours for example, had right beds…Total. Including ER for the really bad days. There was no calling for Cardiology or this or that other department. Unledd there were patients needing a close eye, there wasn’t even a doctor in the hospital side of the building. They stayed on call, in town, waiting for something to happen. I got a fishhook through my face in grade school and they were able to do basic clean up, but the doc had been down the beach fishing at the same time, so he had to make it in before they could stitch me up.

    Just an example. 🙂

  12. Bonnie McKeeganBonnie McKeegan

    I fear the Wrath of the Red Pen! But, I am so glad for your post! My story contains medical scenes…. so, after the creative phase is over I’ll be sure to go back and review/correct and do more research if needed! I bookmarked this post too! Thank you 😉

  13. KateKate

    I grew up in a hospital. My mother was an ICU nurse for 20 years, and used me as the designated visitor for teens and children whose families lived too far away to allow them to visit as often as they would have liked. I spent a lot of time sitting at the nursing station listening to the nurses talk about patients and how their attitude often affected the level of attention they would receive. Make no mistake, all received the same level of nursing care, but some would get the extras, like being offered a sandwich at midnight, or an extra back rub to enable sleep. One topic that I found especially interesting was which doctor they would choose for a given procedure, and which one they would not let touch them for anything more complicated than bandaging a paper cut.

    I am also a frequent flyer in both the ER and OR, having received my first major surgery at 15. Three more abdominal surgeries found me in adulthood and missing a goodly number of nonessential interior parts.

    I chose to live a nontraditional life, having careers in the military, law enforcement, and finally as a professional driver. Trips to the ER are not uncommon in any of these fields, and I had several. Auto accidents that should have killed me, and being run over by a horse that I was training were the ones that also required trips to the OR.

    Your description of ER procedures was most accurate. Both my brother and myself tend to perceive medical dramas as comedy, but the script writers must make each episode interesting, or people will change the channel. The evening news and your daily paper subscribe to the same theory. Drama gains an audience. “Pit Bull Attacks Child”, will draw far more viewers, despite the fact that the dog inflicted a barely reportable scratch while taking the stick that the child was beating him with away from him. Across town, the six year old girl who had her face nearly ripped off by a stray Cocker Spaniel did not even earn a paragraph in the paper.

    Keep up the good work. As a novelist, I try to create dramatic scenes as accurately as possible, and it is refreshing to learn that I am on the right track. Thank you for sharing your knowledge.

  14. Icy SedgwickIcy Sedgwick

    I feel awful because I had a patient wake up and not remember why she was in a hospital bed but it was steampunk and a Wolverine-type scenario! But I try to avoid things like this precisely because I don’t know anything about hospitals aside from visiting other people in them. So this post is brilliant for anyone who, quite frankly, just doesn’t know!

  15. Lizzi TremayneLizzi Tremayne

    Thanks for all this, I appreciate it 100%. I’m an equine vet, so I appreciate it on two different levels…as a vet, and as a horsey person. 🙂 Thanks so much!
    xx
    Lizzi Tremayne

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