Friday, May 31, 2013

Pulling the Plug on a Ventilator

A while back, I was sent the following scenario by an author who asked me to comment on the reality of the situation. 

An elderly Alzheimer's patient with a valid Do Not Resuscitate order is hooked up to a mechanical ventilator (also called a respirator) in the ER by hospital staff who are unaware of the DNR order. The patient is transferred to the ICU where a doctor confirms the existence of the DNR order. The patient is left on the ventilator, but a DNR sign is taped above the man's bed. 

The next-of-kin arrives at the hospital and unplugs the ventilator without discussing her actions with the ICU staff. The book's heroine rushes into the room and attempts to restart the ventilator by plugging the electrical cord back into the wall socket. The relative lunges at the heroine, preventing her from reaching the outlet. Then an ICU nurse arrives and stops both women from any further action. "You can't do that,"  the nurse tells the heroine while pointing to the DNR sign over the bed. "That mean you can't plug it in."

The author of this scenario wanted to know if the next-of-kin could simply unplug the machine as in the story, or if she could order the staff to do it. Would the patient die immediately? Would the DNR order cover this situation, thus preventing anyone from restarting the ventilator?

First of all, the relative could be in big trouble if she pulled the plug. Without a Power of Attorney for Health Care to back her actions, she could be charged with either manslaughter or murder -- depending on the decision of the state's attorney -- if the patient died. Even with such a legal form in hand, she wouldn't be allowed to simply turn off the machine. Instead, she'd have to inform the doctor of the patient's wishes as stated in the POA and request that the ventilator be shut down. Once the POA is presented, the doctor would be required to do as asked and order the ventilator removed. 

As for what the nurse said in this scenario -- "you can't plug it in" -- most experienced nurses wouldn't reply in that manner if faced with such a situation. I believe what would happen is this: The nurse would hit the code button, thus bringing other staff running to the room. She would quickly tell those present what had happened, ask one person to clear the room of visitors (the relative and the heroine), ask another to contact the ICU resident and the patient's doctor, and do all this while disconnecting the intubation tube from the ventilator and reconnecting it to an Ambu bag minus the mask. The nurse would ventilate the patient using the Ambu bag until the resident or patient's doctor arrived. It would be up to the doctor to decide if there is a legal and/or ethical reason to discontinue ventilation, given the presence of the DNR order and the next-of-kin's demands.

People are placed on ventilators for a variety of health reasons. Patients with congestive heart failure, COPD, asthma, or other related lung disorders are often placed on ventilators for 1-3 days until their conditions can be stabilized. Some remain ventilated for longer than that, but are eventually weaned from the ventilator and go home breathing on their own.

Patients who suffer cardiac arrest and are initially treated with cardiopulmonary resuscitation (CPR) generally face intubation, either by paramedics on the scene or on arrival in an ER. The value of CPR lies in its use within minutes of the arrest, before the brain is depleted of oxygen and begins to die. Patients who suffer massive strokes or head trauma affecting the ability of their brains to control their breathing are also intubated and placed on ventilators. 

The decision to stop mechanical ventilation is based on several factors. Medical testing may show lack of brain function in the patient; the brain is too damaged to recover from trauma, stroke, or cardiac arrest. The family may present a legal DNR form or POA form stating the patient's desire not to have his life prolonged by intubation. Even without such forms, consultation with the family may result in a decision to withdraw mechanical assistance if it's judged to be of no value in returning the patient to some level of function. 

As for the author asking if death would occur immediately after cessation of ventilation, my answer must be imprecise. Some patients die within minutes of removal from a ventilator. Others linger for several hours, unconscious but still with some respiratory activity. It all depends on the level of brain function, the ability of the heart to circulate oxygen, and the ability of the respiratory muscles to sustain breathing, all of which are related to the underlying cause of the patient's condition, be it trauma or disease.

More on DNR orders, POA forms, and the newer POLST forms next week here at Cicero's Children. This is all good information for authors seeking to write realistic medical scenes. It's also great information for those of us who wish to control our future medical care. Why leave all the decisions in other people's hands? Doing that doesn't make sense, does it?


Saturday, May 25, 2013

Freebie Fun (And Other Reviews!)

Sometimes you get lucky with Amazon freebie books; you discover an author whose works you just have to read.

I never heard of JB Lynn before I downloaded her freebie novella, The Hitwoman Gets Lucky. I'm definitely going back to Amazon to pick up the first book in this series, though, if only to learn how Maggie Lee became a hitwoman in the first place (and why, after being injured in a car accident, she can now understand the spoken language of her two pets, a Doberman named Doomsday and an anole lizard name Godzilla).

Lynn gives readers only a brief explanation of Maggie's past in The Hitwoman Gets Lucky. The backstory includes some info on her murder mentor, police detective Patrick Mulligan, and her semi-psychic girlfriend, Armani. Also mentioned are her numerous aunts and her niece, Katie. Obviously, we're meant to have read Confessions of a Slightly Neurotic Hitwomanthe first book in the series. Nevertheless, you can get a pretty good take on the complex lifestyle of the heroine in the first few pages of this 2013 novella.

In this story, Patrick asks for Maggie's help in recovering a computer flash drive from Lucky O'Hara, a professional thief working in Atlantic City. The stars seem in alignment for Maggie when her aunt suddenly gives her two tickets to a Barry Manilow concert taking place in--you guessed it--A.C. Maggie and Armani take off for the concert, Godzilla in tow. The smart-alecky little lizard (he has the vocabulary of a college professor) steals the show in this off-beat tale that ends in a mad romp down the Atlantic City Boardwalk.

I found this to be a fun read that introduced me to some unusual, but thoroughly interesting, characters. I'm definitely going back to Amazon for more JB Lynn.

And now, here are two reviews by Carl Brookins.

Ordinary Grace
By William Kent Krueger
ISBN: 1-978-4516-4582-8
A March 2013 Atria release in
HC and as an e-book.

To maintain complete transparency, Mr. Krueger and I are long-time friends, we frequently travel together as the Minnesota Crime Wave, and I received a pre-release copy of this book at no cost to me.

“Ordinary Grace” is a standalone novel, a project the author has long desired to write. The book is considerably different from his multiple-award-winning Cork O’Connor series. It benefits from everything the author has learned over the years writing that series. It is directly and powerfully written, wasting no words, yet always moving the characters and the story ahead at appropriate pace, depending on the actions of the characters and the plot.

Set in a small community in southern Minnesota in 1961, this is how the story begins: “All the dying that summer began with the death of a child, a boy with golden hair and thick glasses, killed on the railroad tracks outside New Bremen, Minnesota.” The narrator is an adult white male, son of the Methodist minister in town. Frank is recalling the momentous events of that bygone summer when he was but thirteen years old, a teen-ager on the cusp of young maturity. The death of that child sets in motion events and revelations of suppressed attitudes that alter the lives and futures of many people in the town. Some of the people affected are important and wealthy, others, as plain and ordinary as one could imagine. Yet everyone in the novel is required to come to terms to greater or lesser degree, with who they are and how they must relate to family, friends, members of their faith, and how they function in the wider yet limited community. What Frank learns that summer, and equally importantly, how he sees and interprets the evil and the grace of that time, will affect him for his entire life. It’s an important lesson.

Krueger’s writing, as always, is smooth and strong and the logic of the plot is easy to follow. While the story has many layers, there are no convoluted or tricky passages readers will have to struggle to interpret. That’s part of the book’s charm and its strength.

The novel explores faith, mysticism, and rationality in thoughtful, even-handed and open ways that lend itself to recollection and continuing reflection, regardless of readers’ experiences in those areas of life. The characters, and there are many, are carefully and consistently well-drawn. This is a novel of discovery and exploration, for the author and for readers. Well done.

Blood, Ash & Bone
by Tina Whittle
ISBN: 978-1-4642-0093-9
A 2013 HC release from Poisoned
Pen Press. 285 pages

Tai Randolph is an unusual character. She’s a southern gun-shop owner with her own set of tattoos and a questionable background. She also sports intimate contacts in her past with some seriously evil people, people like KKK members, like gun and booze runners. She’s also one of the go-to merchandisers of authentic costuming and equipment for Civil War re-enactors. This novel is Randolph’s third adventure.

There are big re-enactment doings coming up and Randolph has to pack up merchandise to set up at the Southeast Civil War Expo in Savannah. The first problem is her history. Savannah is her home town, seat of her family and scene of some of Tai’s most notorious escapades.

Complications arise almost immediately when her ex-lover a scallywag biker-cum-independent entrepreneur enlists her aid in retrieving a long-sought Bible, once thought to have been in the possession of both President Lincoln and General Sherman. Is it real or just a Maguffin? If it’s real, it’s worth a ton of money. According to John, Tai’s ex-boyfriend, the bible has been purloined by Tai’s ex-roommate, Hope. Hope and John were a heavy item some time ago but that relationship seems to have cooled.

Enter Tai’s current main squeeze, a seriously hot but damaged ex-cop, now a security expert for an upscale security firm in Atlanta. He obviously is highly suspicious of anything Tai’s ex boyfriend touches, especially Tai. Now add some layers of interesting active honest and criminally inclined citizens, some with too much money at hand and you have as rich a gumbo as any reader could ask for.
The story is fast-paced, clean and highly evocative of the place. Whether you’ve been to Savannah or not readers will revel in the city scenes and waterfront activity. Whittle knows her characters, her setting and how to tell a fine story. This one is an excellent novel.

A copy of the novel was supplied free of charge by the publisher.

Carl Brookins,
Case of the Great Train Robbery, Devils Island, Bloody Halls, Reunion, Red Sky
more at Kindle, Smashwords & OmniLit!


Wednesday, May 22, 2013

Lets Eat Grandma??

We all know when to use a comma, right? Well...not really.

Some writers sprinkle commas into their sentences like fast-food chefs sprinkle salt on French fries; the more commas/salt, the tastier the sentences/fries. 

Other writers avoid commas like they're the plague, either out of fear of misusing them, or because they really don't see a comma as a necessary punctuation mark in certain sentences. 

(Of course, the most common reason writers omit a needed comma is because our fingers are flying over the keyboard faster than our brains can spot our mistakes!) 

The T-shirt example above shows how a sentence can be misunderstood when the comma is omitted. The most common comma error I see when editing manuscripts is the omission of a comma between an exclamatory word (hey, oh, wow, etc.) and the name of the person or term of endearment following that word.

Example: "Hey Tom, let's go!" should be "Hey, Tom, let's go!", or even better, "Hey, Tom! Let's go!"

In the same way, "Oh honey, you look so worried." should be "Oh, honey, you look so worried."

In the first example, Hey Tom is not the man's name. It's Tom, pure and simple, so insert a comma. As for the second example, terms of endearment--honey, dear, sweetheart--are always separated from other words by commas, regardless if they start, end, or are in the middle of the sentence.

Another common comma error occurs when words are listed in a sentence. Lists of three or more words should be separated by commas.

Example: "I went to the store with my uncle, cousin, brother and best friend."

Read this way, the speaker went to the store with three other people: an uncle, a cousin, and a brother who is also the speaker's best friend. 

This could be true, but what if the speaker actually went to the store with four other people? Then the sentence would have to be written this way: 

"I went to the store with my uncle, cousin, brother, and best friend." 

Now we know the brother is not the speaker's best friend. The best friend is a fourth person accompanying the speaker to the store.

A well-placed comma is a writer's friend. On the other hand, too many commas can annoy the reader. Why? Because they usually occur in sentences that are too long, too descriptive, and/or too complicated to be easily understood.

Consider this sentence:

"I was going to the store when, much to my amazement, I saw a bird, smaller than a hawk, but larger than a dove, fly into my neighbor's tree, the one by the corner, not the one in the yard, where it began pecking at the trunk in a most unusual, but not unpleasant, way, until my neighbor's wife, her long, golden hair streaming behind her, ran out of her house brandishing a spindly, brown broom in one hand and a dirty, wet dishtowel in the other while screaming at the bird in a loud, almost raucous, tone of voice."

An annoying sentence? You can say that again! :)


Thursday, May 9, 2013

Pediatric Brain Tumor Awareness Month

May is Brain Tumor Awareness month. As many of you know, my granddaughter Cinnamon Rose is a brain tumor survivor. Her tumor was discovered when she was 18 months old. It was inoperable, but thanks to new chemo drugs and protocols for children, Cinnamon underwent chemo treatments, and after 18 months of that, she was tumor free. She will turn 12 next month and is still tumor free. My cousin's granddaughter has not been so lucky. Her tumors were discovered 5 years ago, and after surgery and many months of chemo, she was thought to have won the battle. Unfortunately, her tumors returned in an even more aggressive state. As of today, Caitlin will be leaving the hospital tomorrow to face end-of-life care at home. Please pray for Caitlin. Please pray also for her mom and dad, who are undergoing the worst that life can throw at any parents, and for her brother and grandparents, who love Caitlin so very much. And please support the Pediatric Brain Tumor Foundation, . They fund research on new meds and other treatments for children with brain tumors while also supporting the families of these young patients. Brain tumors are the leading cause of cancer deaths in children, surpassing even leukemia. Thanks for reading this, and thanks for your prayers and help.


May 17, 2012

Today I received the following news: "May 17, 2013, 8:27am, Caitlin breathed her last breath here on Earth. She earned her Angel wings and is at peace now." Please keep Meri, Jim, little Jackob, and Caitlin's grandparents and family in your thoughts as they go through the difficult days ahead. Thank you.

Sunday, May 5, 2013

E = Eliminating Errors

Last month I mentioned an acronym I use when editing my writing. (see April 15 post) Following that post, I wrote about sentence structure, the "S" in my "Self-Editing" acronym. Today I'd like to discuss the "E in "Self-Editing" -- Eliminating Errors. 

The most common writing errors occur in spelling, and even though most of us use spell check when editing our work, mistakes still happen. 

I can attest to that in my own work. Just this week I received an email from Dana, my editor at Harlequin, in which she commented that she found and fixed a typo in my manuscript of THE RUNE STONE MURDERS, the cover of which is shown above. (Release date: June, 2013) Now, I went over that manuscript at least three times before sending it to Dana, but obviously my eyes saw what my brain said I'd meant to type, not what I'd actually typed. That's because, like all writers, I was too close to my own work, and I knew instinctively what each sentence should say. Our brains can trick us that way, which is why we all need editors, people without preconceived notions of what they're seeing on the written page, people who can look at our work in a totally objective manner. 

Sometimes we spell a word correctly, but it's the wrong word for the sentence. In THE RUNE STONE MURDERS, I meant to write "he went to his death", but I actually wrote "he was to his death". Spell check didn't catch my mistake because I'd spelled "was" correctly. As good as it is, spell check can't read our minds. 

Common word mistakes I've seen in manuscripts include "there" for "they're" or "their", "hear" for "here", and "witch" for "which".
Again, spell check won't catch those kinds of mistakes because the misused word is spelled correctly.

Sometimes writers incorrectly capitalize certain words. I recently read two novels by two different writers in which the main characters worked as real estate agents. Both authors repeatedly called their character a "Realtor" rather than a "realtor".  Just like we don't capitalize the words engineer, doctor, scientist, conductor, or police officer when referring to a person's occupation, we don't capitalize the word realtor. 

Nicknames in sentences are capitalized. Example: "Rich is a tough guy; that's why we call him Gruffy." A second example: "Paul 'The Waiter' Ricca was a Chicago mobster and a close friend of Joseph 'Diamond Joe' Esposito." 

Terms of endearment are not capitalized. Examples: "Let's go to the store, honey." "I really don't want to go, sweetheart."

Do you capitalize the first word after a colon? It depends on which style manual you use (or which one your publisher requires you to use). The Chicago Manual of Style recommends you use lowercase lettering for the first word after a colon unless that word is a proper noun or the start of at least two complete sentences or a direct quote. The Associated Press Manual of Style recommends you use lowercase for the first word unless it's a proper noun or the start of one complete sentence. The AP manual makes no mention of a direct quote following a colon, but one can assume that all direct quotes begin with a capitalized word.

In my next post I'll discuss errors in punctuation and POV. See you then!