Friday, August 31, 2012

Rizzoli & Isles: Death by Drugs

I am a huge Rizzoli and Isles fan. I love both the TV show and the novels by Tess Gerritsen on which the show is based, even though the two are very different.

Anyone who's read Gerritsen's books knows that the producer made some big changes to the two main characters when the TV series went into production. Jane Rizzoli became a street savvy tomboy who eschews dresses and high heels for sweatsuits and gym shoes. Maura also changed into a wackier version of the brilliant pathologist portrayed in Gerritsen's books. Secondary characters were added or transformed in order to appeal to a broader based audience.

Until recently, I was pleased that the producer at least had the good sense to leave the science alone. Gerritsen is a master at writing realistic medical scenes and making sure Maura Isles is up-to-date on the scientific side of crime solving. There are no medical mistakes in Gerritsen's books.

But there sure was a big medical mistake in an episode of the TV program a few weeks ago. A wealthy young man wearing a mask and a cape died suddenly during a kinky sex party. During the autopsy, Maura discovered he'd been INJECTED with POTASSIUM CHLORIDE in an amount sufficient to cause a cardiac arrest. Rizzoli's investigation eventually led her to the wife of the dead man's partner. The police decided she was the logical killer mainly because she was a school nurse and thus had access to potassium chloride and how to inject it in order to kill someone.

WHAT????????

I practically leaped out of my chair at the stupidity of that claim. The writers really got that wrong!

First of all, potassium chloride in its injectable form can only be bought if a veterinarian has prescribed it for use in the care of a sick animal and the individual buying it has a prescription signed by the vet. Even then there are difficulties getting it from an ordinary pharmacy. Generally one must buy such a product from a pet care company that deals in veterinary medicine.

Doctors DO NOT prescribe injectable KCl (potassium chloride) for use by non-medically trained individuals because of the extreme danger of death by overdose. Injectable KCl can only be found in hospitals where trained pharmacists dilute it in solutions of normal saline (NS) or 5% dextrose in water (D5W), or in other medical facilities equipped to administer IV potassium chloride in solutions.

Diluted KCl is given intravenously in varying amounts depending on the  need. Normal human potassium levels range from 3.5 to 5 mEq/L in the blood. If someone has a level lower than 3.5, that person is said to be suffering from hypokalemia. Mild to moderate hypokalemia can be treated with potassium in pill form. Severe hypokalemia, where the potassium level is less than 2.5 mEq/L, is generally treated intravenously using the following solutions: 10 mEq in 100 ml of solution; 20 mEq in 250 ml of solution; or 40 mEq in 500 ml of solution. Depending on the amount of KCl given, it will be infused over a span of one to four hours.

Why so slow when it comes to infusing KCl, you ask. Well, the truth is, the stuff hurts like heck if given too quickly. Patients will complain that the arm with the IV in it feels like it's on fire. If it hurts that much when diluted with saline or dextrose, just imagine how painful it would be if your imaginary killer injected straight undiluted potassium chloride into a victim's vein. Unless the injection was made in a vein close to the heart, the victim would have at least a few moments in which to scream.

How much KCl would it take to kill someone if it was injected undiluted into a vein? Now we're talking what's called LD50 -- the lethal dose for 50% of people weighing 75kg, or 165 lb. It's been estimated that the lethal IV dose of KCl is 30 mg per kg of body weight for a person weighing 75kg, and it has to be injected quickly.

So let's say your killer got his hands on a 10 ml (10cc) bottle containing the usual 2mEq/1ml of injectable KCl. That's 20 mEq KCl in a 10 ml bottle. He needs 30mg/kg, and his victim weighs 75 kg. Multiply 30 x 75 and you get 2250mg of KCl needed to send the victim's heart into an abnormal rhythm that would in all probability lead to a rapid death. 2mEq of KCl = 150 mg, so a 10 ml bottle would contain 1500 mg. Your killer would need to use at least 1 and 1/2 bottles -- or 15 ml (15cc) -- and would probably feel safer going with 20 ml (20cc), the entire contents of two bottle.

Now have you ever seen a 20cc syringe? They're not those little syringes used when you get a flu shot, or the even tinier ones used to administer insulin. They are BIG syringes, not easily hidden in your hand or your pocket. They're not the kind you can easily buy, either.

What I'm trying to say here is this: the SCHOOL NURSE in that episode of Rizzoli & Isles didn't have the ability to get her hands on injectable KCl. School nurses don't have access to that kind of drug, and she had no access to a hospital pharmacy. The only way she could have gotten it was through her pet's vet. But NO MENTION was ever made of her having a pet of any kind, healthy or sick, so forget the vet idea. And where did she get the 20cc syringe, and how did she hide it in the gauzy little outfit she was supposedly wearing when she killed the guy?

Writer mistake, for sure. Now if you're thinking of including a death-by-potassium-chloride scene in your book, remember what you read here and WRITE IT RIGHT!

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Friday, August 24, 2012

A Scene in a Small Rural ER

As promised, this week I'm adding a new feature to CICERO'S CHILDREN called THE WRITER'S ER that will highlight questions from authors concerning medical scenes in their books. As a long-time ER nurse and instructor in ACLS, PALS, and BLS, I have the experience to answer most any question thrown my way. And if I'm ever stumped for an answer, I have friends in the medical field, especially in the field of pre-hospital care and ER care, who I can turn to for help.

That said, the first question I received this week was from Marilyn Meredith, author of over thirty published novels. Marilyn writes the Deputy Tempe Crabbe series under her own name, and the Rocky Bluff P.D. series under the name F. M. Meredith. She is a member of Epic, three chapters of Sisters in Crime, Mystery Writers of America, and serves as the program chair for the Public Safety Writers of America's writing conference. 

Marilyn has been an instructor at many other writing conferences. You can learn more about her books at http://fictionforyou.com. Please visit her blog at http://marilynmeredith.blogspot.com. . 

Marilyn wrote: "I have a character who is a young police officer and she’s been shot in the thigh and shoulder—bled a lot but neither serious. Another officer stopped the bleeding at the scene, she’s taken to the ER, and then where? I want her friend another female officer to be able to see her before they take her to the operating room. One of the nurses is a friend of the 2nd officer (her husband is a police officer too.) She would’ve had x-rays, right? And be getting IVs? Is there a window of time where her friend could speak to her?"

I emailed my answer to Marilyn who graciously consented to let me post her question here. (I'm including a bit more information below then I originally gave to Marilyn. That's because I wanted to clarify what I wrote about the different levels of trauma centers.)

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Yes, Marilyn, there's a window of time when the friend would certainly be allowed to speak with her. That window could be quite large depending on where the injured officer was taken. Are we talking a small rural hospital, or a small, medium, or large city hospital? Population determines the size of a city, with the criteria differing from state to state in the U.S. In a large city, an officer with multiple GSW would be taken to a Level I trauma hospital where surgeons of all specialties are on duty 24/7. Generally speaking, a medium sized city might have a Level I trauma center if it served a larger population outside its city limits. It would definitely have a hospital certified as a Level II trauma center with surgeons of all specialties available to come in within 30 minutes of being called by the ER doc. An example of a medium-sized city that has both a Level I and a Level II trauma center is Aurora, Colorado (population 325,078). One hospital in the city serves as a Level II trauma center for all patients, while another hospital serves as a Level I Pediatric Trauma Center dedicated to injuries in children.

Small cities could have a Level II or a Level III trauma center, Level III being a hospital that can provide care to most trauma patients, but doesn't have a full range of specialists. Level III ERs transfer patients to a higher level trauma center if they require more intensive emergency treatment by a specialist. An example of this would be a gunshot wound to the head that required the services of a neurosurgeon.

There are always exceptions to the city size rule. The population of Park Ridge, Illinois is only 37,775, but it has a Level I Trauma Center. Lutheran General Hospital opened in 1959 when there was still much open land in this Chicago suburb. Over the years it grew, and grew, and grew, until today it is a 645-bed medical center and one of the largest hospitals in the Chicago area. You could probably find the same story playing out in small suburbs of other major cities. But when we're talking about rural areas such as you'd find in states like Utah, Nevada, Oregon, or even in parts of California, you're looking at your hospital being a Level III trauma center. Examples of this would be Yreka, CA (population 7,765) and Wildoma, CA (population 32,176). Both cities are served by Level III trauma centers

In a Level I or Level II hospital ER, the ER doc would not call in a surgeon for a basically non-serious GSW until he had completed his examination and had X-ray and lab results, because he/she would need to know if a surgeon was needed and what kind of surgeon was required. He'd probably call in an orthopedic surgeon if the bullet shattered bone, but the possibility of nerve damage could require a neurosurgeon as well. If your hospital is in a rural area serving maybe 15,000-20,000 people, the hospital would probably have a Level III ER and would transfer the patient to a higher level facilitya Level I or II hospital—if the necessary surgeon wasn't available there.

Even in a Level I or Level II hospital trauma center, your officer would be in the ER for at least 2-4 hours prior to going to surgery if the shooting occurs during the day and if, as you say, those wounds are minormeaning no major arteries were hit and bleeding is controlled. I say "during the day" because the OR suites are already in use during the day, and the only way your victim would be pushed to the front of the OR schedule is if she is bleeding so badly that her blood pressure falls and she goes into shock, the wound is to the chest or abdomen, or the gunshot caused a partial amputation of a limb or some other life-threatening event. She'd probably go to the OR faster in the evening when the OR isn't in regular use. I'd still count on at least 2 hours from arrival in the ER to going to the OR in the evening.

Your victim would have at least one IV in place with a liter bottle of .9 normal saline running slowly, plus an IV line with a heplock in place, that line not being used at present but reserved for use if needed in surgery (more fluids or blood products). X-rays would be taken to look for bone damage and, if the bullet did not exit the wound, to see placement of the bullet in the body. Lab work would be done, a CBC (complete blood count), PT and PTT for clotting evaluation, and probably chemistries (electrolytes, etc), plus a Type & Screen for possible blood transfusion. 

Shoulder wounds can be life-threatening because you have the subclavian and brachial arteries and veins running below the clavicle and down the arm. In order to make them minor wounds, your victim needs to be shot clean through the deltoid muscle on the outer fleshy area of the upper arm. If the bullet doesn't touch the bone but lodges in the muscle, the ER doc can remove the bullet without calling in a surgeon. If the bullet goes clean through without damaging the bone, the ER doc will clean the wound, close it with sutures, apply a dressing, and discharge the patient with antibiotics (may give IV antibiotics also before discharge). If the bullet penetrates the upper arm bone (the humerus) breaking that bone or causing bone splinters to lodge in the surrounding muscle, an orthopedic surgeon would be called in for surgery to remove the bullet and clean up the splinters and/or repair the fracture with plates and screws. Your officer would be out of action for several weeks if the bone was broken, but less time if just a few splinters were removed, maybe 10 days and no heavy lifting for another week. If shot through the clavicle or shoulder blade (scapula), generally no surgery would be needed unless it's for the removal of bone splinters. Treatment for a shoulder blade is a sling. Treatment for a clavicle is a figure eight strap. 

For the thigh wound, if you want it to be minor, the wound must be on the outside of the leg. The femoral artery and vein run down the inside of the leg, and both bleed like mad. Hitting them with a bullet, especially the femoral artery, could cause your officer to bleed out very quickly. Go for the outer fleshy part of the thigh. You'll probably have to have the bullet hit the femur (the upper leg bone). It's hard to miss the femur unless the officer has really fat legs. :) If you want your officer back on her feet quickly, just have the bullet graze the bone so the surgeon just has to remove some splinters. The femur is the strongest bone in your body and doesn't break easily in a younger healthy person. Your officer will be on crutches for a day or so, then may use a cane until she has no pain when weight bearing.

So again, if the wounds are minor, your officer will wait around in the ER for several hours, during which any of her friends can visit her. If she's going to be transferred to another hospital for surgery, it'll depend on how long it takes for an ambulance to arrive for the transfer. We're still talking a couple of hours here because of all the tests, etc.

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And now a heads up to writers like Marilyn and I who include ER scenes in our novels. Be careful of the kind of injury you create for your hero or villain. If you set your stories in rural areas, don't expect to have a thoracic surgeon or a neurosurgeon living right down the block from your hospital. Big money guys like those  tend to stay in the big cities where they have plenty of work to do every day. If you're not sure what kind of hospital ER you should portray in your story, check out hospitals in real areas similar to you setting. For more information on trauma centers, check out the following links:

http://www.facs.org/trauma/verified.html A partial list of trauma centers by American College of Surgeons.
http://www.traumamaps.org  A map of the U.S. showing trauma center availability.
http://www.cdc.gov/traumacare/ Info from the CDC.
http://www.calena.us/California%20Hospitals%20and%20Trauma%20Centers.htm   The Emergency Nurses Association of California's list of state trauma centers.  

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IF YOU HAVE A MEDICAL QUESTION DEALING WITH PRE-HOSPITAL CARE OR CARE IN THE ER, AND WOULD LIKE TO HAVE IT ANSWERED HERE, CONTACT ME AT KLEWORKS@AOL.COM. I'D LOVE TO HEAR FROM YOU.



Tuesday, August 14, 2012

A NEW LOOK COMING TO CICERO'S CHILDREN

I'm happy to announce that, starting next week, I'm adding a new feature to CICERO'S CHILDREN. 

You'll still be able to find book reviews and other news here, but the main thrust of this blog will be to help writers who include medical scenes in their books, especially scenes set in the ER or scenes dealing with pre-hospital paramedic care.

Research is the keystone to successful writing. Set a scene on a bus in Chicago, and you'd better know if buses actually run in the neighborhood you're portraying. Plot a car chase in New York City, and you'd better know if the avenue you've named goes both ways or is a one-way street.

The same applies to medical scenes. I recall reading a thriller written by a surgeon. His surgical scenes were right on spot because he knew his subject well. But then he placed his characters in the ER, and everything he wrote about the care given to a child before and after arrival in the ER was wildly wrong. It was obvious that our surgeon/writer hadn't run this scene past an ER doctor or ER nurse or a paramedic.

So to help writers who want to get it right when they portray a medical scene, I'm instituting a Q&A section here along with a medical tips section. Want to know if there's a neurosurgeon in your small town who's capable of treating a gunshot wound to the head? Want to know if your gunshot-wound-to-the-shoulder victim should walk out of the ER with his arm in a cast? Want to know what a paramedic would do for a heart attack victim before arrival in the ER?

Then THE WRITER'S ER at CICERO'S CHILDREN is the place for you. Enter your questions in the comment section below, or email them to me at kleworks@aol.com. As a veteran ER nurse and instructor in ACLS, PALS, and BLS, I'll give you an answer you can trust. And if I can't give you an answer (which I doubt), I'll ask my ER doc friends and/or paramedic buddies. One way or another, I'll help you "write it right".

Remember, THE WRITER'S ER starts next week here at CICERO'S CHILDREN. I hope you'll drop by and check it out.

Until then, here's a bit of news from Julia Buckley.


"I'm launching my first YA novel on Kindle today. It's called GINEVRA BOND, and it's not a dystopian nightmare; instead, it's the story of one young woman whose psychic abilities make her a valuable commodity and therefore put her in danger. Here's the link." 


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And now, another new book review by Pat Browning.

THE BLUE HACKLE , A Jean Fairbairn/Alasdair Cameron Mystery

By Lillian Stewart Carl
ISBN-10: 1594149224'ISVN-13: 978-1594149221
Reviewed by Pat Browning

I’m a traditional reader. I like to know where a story takes place. Too many stories I’ve read lately could happen anywhere. Not so with Lillian Stewart Carl’s THE BLUE HACKLE, set on the Isle of Skye .
 
I’ve been to the Isle of Skye. I’ve tromped hither and yon on a cold misty day. I’ve snapped photos of Dunvegan Castle. I’ve enjoyed tea and scones before the fireplace of a local inn. Lillian Stewart Carl’s descriptions ring true, and I thank her for giving her jewel of a ghost story a proper setting.
 
Jean Fairbairn, part-historian, part-journalist and lately of Texas, and retired Scottish Detective Inspector Alasdair Cameron of Edinburgh, are on Skye as guests of Fergus MacDonald, owner of the decaying Dunasheen Castle. “Fergie” hopes to make some money by opening the castle to paying guests. Jean and Alasdair plan a New Year’s wedding at the castle. And of course the old castle has a resident ghost, The Green Lady.
 
Poor Fergie. He plans a festive, profitable Hogmanay celebration. He gets murder, attempted suicide, cops swarming over the estate, reporters pounding at the gates, a clandestine love affair, a wayward wife, a questionable inheritance, and a throwback to “clan feuds, arguments festering for centuries.” This bunch keeps The Green Lady busy.
 
Jean Fairbairn is a delightful character. She’s nosy the way a journalist/historian should be. Her senses are fully engaged. She hears things, sees things, smells things, tastes things. She’s sensitive to the presence of ghosts and adds humor to the story.
 
It’s Jean who spots a sheath missing its dirk, the traditional and ceremonial dagger of officers of Scottish Highland regiments. One of the guests, a wheeler-dealer from Australia, has been stabbed to death. The missing dirk may well be the murder weapon, throwing suspicion on someone inside the castle, not on a wandering vagrant or other outsider.
 
Alasdair is the perfect opposite of Jean: the dour Scot at his most attractive, the sturdy and dependable companion. He, too, is “allergic” to ghosts, as is Dakota Krum, young daughter of the guests from Maryland.
 
The lively and curious Dakota stumbles upon the hidden grave of someone “known only to God." Jean and Alasdair speculate that the deceased was a key player in an old murder who returned to be reunited with the ghost of The Green Lady. Jean ponders the possibility: “Maybe death was a dream. Maybe life was. Maybe it all flowed on together, no now, no then. That would explain synchronicity, ESP, and ghosts in one fell swoop.”
 
Fergie shows Jean and Alasdair an ossuary he had meant to sell to the Australian. He believes it held relics of Jesus Christ. When he launches into a tale of fairies, Crusaders and alien astronauts, a despairing Alasdair fears his old friend has gone mad.
 
Jean demurs. “The true believers, they get me at ‘what if.’ … People used to see angels. Now they see UFOs. Seeing is believing, and believing is seeing. Never underestimate the will to believe or the will to exploit belief.”
 
The cops work the murder the traditional way: interviewing and re-interviewing witnesses and suspects, and picking up on local gossip. The investigation continues even while the New Year is chimed in at the castle. The doorbell rings, ushering in another complication. The story picks up steam, and the author wraps up all story threads in a nail-biting denouement and a thoroughly satisfactory ending.
 
A word about ghosts:
I did some Googling and turned up a quote attributed to Albert Einstein: “Energy cannot be created or destroyed; it can only change from one form to another.” That led me to The Law of Conservation of Energy (aka the First Law of Thermodynamics) and theories going back to ancient Greek philosophy.
 
That led to the theory espoused by the Persian scholar Nasir al-Din-al Tusl in the 13th century: "A body of matter cannot disappear completely. It only changes its form, condition, composition, color and other properties and turns into a different complex or elementary matter." I ended up with Albert Einstein's theory of mass-energy equivalence stating that nothing is either created or destroyed; it merely changes from matter to energy and vice versa.
 
Those theories and experiments are still argued about today. Fortunately, I am neither a physicist nor a philosopher. Just thinking about it gives me a headache. But I do love ghost stories.
 
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