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:
These are great posts! Thank you, Kim.
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