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.
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.”
- 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.
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.
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.
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
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