Tuesday, May 8, 2018

Medical Writing...from the nurses aspect

The last few months I have talked about the medications and injuries of the Old West but in order to bring this full circle for writers/authors I’ve got to go a bit more current or modern. First disclosure, I am not a doctor. Doctors and nurses think differently but are focused on the same goals. After 28 years in an acute care facility, it is easy to see the change in the relationship between physicians and highly skilled nurses. The docs rely on us a lot to help put together the picture that is going on with the patients. Still what is presented here will let you know that these kinds of injuries today can often result in death and even more so in your historical novels.

Nurses are no longer thought of as bedside hand maidens as they were back in the 1800’s and before. If your heart stops in the hospital, it isn’t the doctor doing what is needed. He is probably there shouting the orders, but it is the Registered Nurse who is pushing the medications. It is the Registered Nurse who is starting the IV and inserting an enterotrachial tube so you can breathe. It is the Registered Nurse who is monitoring your vital signs and it is a Registered Nurse who is monitoring the screens and equipment that tell how you are doing. But it is also the RN who is outside the room, holding your husband’s hand. It’s the RN who is the first one to hold your child once the physician passes off the bundle. It is the RN who sits with you when you are afraid and who offers you a smile when the diagnosis seems grim. You don’t know it but she had prayed for you, cried about your pain and researched hard to find the answers. She is the one who says you can do this during your recovery. She is the one who cheers you when you reach even the small goals and she might ever be the only one there when you take your last breath. She cried then too, but there is reward in being a nurse and many of us have found that. That’s the pretty picture. Here is the reality. I have been hit, bitten, scratched, spit on, cursed, pee’d on, pooped on, shoved, degraded, badgered, threatened and that is just before lunch, but the good always seems to out weight the bad, like just one patient who really appreciates what you do.

But onto the writing medical things…
What I find when I am reading stories where characters are injured is that often times the medical information isn’t correct or isn’t what a nurse would say. I’ve also read a few where the medical position isn’t described as it really is. So first let me discuss the roles in a hospital beginning with nurses and techs. So I have several things I can cover.
Nurses Defined
Licensed practical nurses (LPNs)---licensed vocational nurses (LVNs)-Work under the direction of an RN and train most often in Technical Colleges, though a lot of these programs are being phased out. 
Registered Nurses-Usually a 4 year Bachelor’s of Science Degree from a college or university. Practice under physician orders, but most often independently.
Advanced Practice Nurses:
Nurse Anesthetists-(CRNA)-Nurses who train further to administer anesthesia. They often work under the orders of an Anesthesiologist but do practice independently.
Clinical Nurse Specialists-Often in Educator Roles, but this seems to be phasing out in most programs where Nurse practitioner programs are growing.
Nurse Practitioners-Work in a variety of specialties from offices to hospital setting and even public health. A degree higher and specialized such as geriatrics, family practice or emergency medicine. NP’s have prescriptive rights in most states and are highly paid in rural areas where doctors are not available.
Certified Nurse Midwives-Highly Trained to deliver babies under a physician’s guidance. Prescriptive rights also. 
Ancillary Nursing Staff:
Certified nursing assistant- Assists RNs and LPNs with vital signs and basic patient care from baths to potty help. This is obtained in six or eight month certificate programs, but they are not nurses.
Nurse Tech-Patient Care Tech-Often trained to do a little more than a CAN. For the most part candy stripers and orderlies are non-existence. There are also a large number of male nurses these days.
Orderlies and Candy stripers rarely exist any longer. There are transport teams to move patient from one place to another but most of those employed in the role have some medical training. The emergence of HIPAA laws on confidentiality had made it where you can no longer have as much access to medical facilities or patient information so be careful in writing what is happening to your characters on what may be told over the phone or what may be seen or done while in a medical facility.

Other Roles in the Hospital:
Physician Assistants-Trained to work alongside a physician, making rounds and even assisting with orders and the plans for patient care. Highly skilled.
Hospitalists/Internists-Hospitalists are hired physicians that work on staff to monitor patients within the hospital. Internists specialize in the care of ICU patients.
Anesthesiologist-Administer Anesthesia for surgery cases and or pain blocks such as epidurals.  
Pharmacists-Specialize in measuring and mixing medications that are ordered for patients.
A note to writers: Not all docs are rich, some have a years of student loans to pay back and others pay dearly for the required malpractice insurance. For example the insurance for an OB/GYN physician can be in excess of 150,000 a year. Today’s physicians often work in large group offices and time is money. Physicians do not typically work for the hospital but have privileges to admit and treat their patients. A lot of people think the doctor works for the hospital.
Emergency Medical Technicians (EMTs) and Paramedics-Most often are firemen with advanced training for responding to accidents and injuries outside medical facilities. EMT do first aid type care and emergency care, but paramedics are trained to push medications in the field and are highly skilled.
Medical Assistants (MA). Trained to run the front and back offices or clinics. Can draw blood and also run the billing of an office for example.
Occupational Therapists—Work to assist for instance stroke patient to regain functional use of limbs at least to be able to perform the activities of daily living.
Physical Therapists—Assist with regaining full use of injuries, to help relieve pain, to assist patients who have been bedridden to get up and about again after surgery, plus much much more.
Speech-Language Pathologists-Assist with feeding issues and regaining speech after stroke or other injuring.
Most people in these positions are happy to allow an interview of what they do on a day to day basis. HIPAA laws sometimes limit shadowing experiences, but most will answer phone interview questions or meet away from actual patients. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that requires employers to protect employee medical records as confidential. HIPAA includes regulations that cover how employers must protect employees’ medical privacy rights and the privacy of their health information. Tis law also means that staff do not discuss patient information over the phone except to give a basic condition: Stable, critical etc.
Even if you are not writing medical romance, your hero or heroine may be injured and often times the care or the scenes are not described correctly. Do your research! Interview your doctor or a nurse friend.
Writer Tips: Remember a couple of things. Your hero is not going to bounce back from some of these injuries very quickly. Don’t give him a concussion and fractured ribs and then have him making love the next day or in the next chapter.  Broken bones can take 8 or more weeks to heal and it isn’t likely he’ll feel up to it for a while even if he is a Scottish Highlander or Hot Cowboy.
Vital signs are the first thing often checked on a injured patient, so let’s talk about the normals. Most searches for medical information will offer you similar parameters. There are all kind of medical websites offering free information. I have not listed any here because there are so many. My favorite book for research is the Merck Manual-. I lived with that in my hands as a nursing student and new nurse. It sits on my desk at work still. It runs from $50 to $75.00 but is well worth it.
And to understand the life of a nurse, Echo Herron wrote Intensive Care and Condition Critical. The first is the best example of how it was to survive nursing school and the later is how it is in the real world of nursing. Both are great reads.

So on to vital signs. I think a lot of writers have trouble describing vital signs in rescue scenes for instance.
Temperature: Normal is 98.6--Children can run a high fever up to 104, but at 104 the adult is really ill. Ice packs, not heavy blankets, but cooling blankets.
Pulse: Normal 60-90.  Describing Pulses: (Never check a pulse with your thumb-because you will count your own pulse and not the patients!)
Strong-normal rhythm
Bounding-unusually strong rhythm-running or the heart working hard

Thready-pulse beats are weak-losing blood or in shock

Irregular-does not have a regular beat, skipping beats-heart issues

Regular-regular rhythm- “The pulse is regular, 80”

Respirations: 12-20. Someone having an asthma attack might breath as rapidly as 60 breath a minute, but they are having symptoms. Audible wheezing etc. After a time of not getting in enough oxygen, the rate might begin to fall as you lose the person.
Blood Pressure:  Systolic (top number) 100-130    Diastolic (bottom number) 60-90. If someone is injured or in pain the blood pressure will initially rise, but if they continue in crisis or are losing blood and the loss isn’t stopped, the blood pressure will then fall. This is when you are losing the patient. The newest guidelines on blood pressures is systolic under 120 and diastolic under 80 or the patient is labeled pre-hypertensive.
Nursing Duties beyond Vital Signs: Coordinating and prioritizing multiple patients doses of daily medication which must be given within thirty minutes of the time due. This might involve by mouth pills and tablets, injections and Intravenous fluids. Follow the plan of care: Nursing Diagnosis and Assessment of each patient multiple times a shift, implementing nursing diagnosis, interventions and assessing outcomes. Record and document all necessary information, communicate with peers, subordinates, supervisors and other members of the healthcare team, research, follow legal and facility standards, teach patients, resolve issues, inspect and work equipment, maintain patient confidentiality.
Don’t forget that in history while many survived the injury, they often died of bleeding and infection some days later. Gunshot wounds-might have died right away, but many died days or even week later of infection/gangrene. Stabbings-some died right away but others might have developed infections that took them weeks to die from. Disease and illness-no antibiotics, but often herbal remedies and many died from the things we easily cure today. Writer Tips: Hand washing was a huge issue along with sanitation and cleanliness, often leading to infection if someone did survive the injury.

Stay Tuned next month for Emergencies then and now!

1 comment:

Kristy McCaffrey said...

These are great posts! Thank you, Kim.