Vital Signs During a Cardiac Arrest Scene

I am writing a scene in which a patient goes into cardiac arrest and eventually flatlines. Can you provide a blow by blow of the vitals? What is a bad BP level and how does that progress from caridac arrest to flatline. For example, it might start BP at 110 over 50 and then go above 180. How might a doctor or a member of the crash team say them (e.g., "BP is 180 over 50. Heart rate is 92 and climbing.") Are there other vital signs to look out for?

Hello, Paco.

It’s A, B, C, D. Airway, Breathing, Circulation, Defibrillation.

In a cardiac arrest, the vitals we’re interested in are: respirations—is the patient breathing or not? Pulse—is there one, and what is the heart rate if there is? Blood pressure—which is only present when there’s a pulse. If your patient has no pulse, no need to check a blood pressure—you can’t get one!

During the cardiac arrest, the rhythm will be asystole (“flatline”—no heart beats) ventricular fibrillation (a jerky irregular rhythm) or ventricular tachycardia (a very fast rhythm that generally produces no effective blood pumping action).

As the code blue starts, the person in charge of the resuscitation will keep their fingers on the pulse—often at the groin. Someone will be doing CPR. If the patient doesn’t have a breathing tube down, someone should be holding a mask over the patient’s face and be pushing air in with a bag—(“bagging the patient”)

For any of the above rhythms, the defibrillator will be tried first, at a charge of 300 joules, to shock the heart into rhythm.

So, you’d have:

“No pulse. Start CPR.” (someone starts CPR)

“Charge to three hundred Joules.” (High-pitched whine as defibrillator charges, beeps when charged)

“Everybody clear.” (everyone steps away from the patient and the bed. The person in charge of the code gets the paddles and places one in the center of the patient’s chest, one on the left). “Clear.” (the shock is delivered). “Rhythm is bradycardia at thirty.” (slow pulse, 30 beats a minutes)

Check to see if there’s a pulse. If yes, try to get a blood pressure. It can be low. For simplicity, consider 90/50. Turn up the IV fluids to expand blood volume. If patient is breathing on his own, transfer to ICU if patient not in ICU. A normal pulse is 60-100. A normal BP is 120/70. Too low is 80’s on the top number.

If the shock isn’t successful:

“Resume CPR.”

Epinephrine will be given IV:

“Give an amp of epi!” (CPR continues while this is happening; wait a few seconds for drug to kick in)

“Charge to three sixty.” (360 joules)

If successful, as above. If not, continue CPR, bagging, and give an amp of bicarb (helps correct pH), an amp of atropine (speeds up heart) and another amp of epi. Another shock.

At some point, the person in charge of the code is going to “call the code,” meaning stop due to no success and little likelihood of succeeding with continued effort.

~*~ 

Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it.

Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.

Guarding a Surgeon in the Hospital

My heroine is a surgeon. Someone has made several attempts on her life. The hospital has insisted she have a bodyguard. Here are my questions: 1) Would he be allowed to carry a weapon? 2) Would the bodyguard be allowed to be in the OR with her, or would he be stationed outside the OR doors?

Most hospitals don’t allow “carrying” unless the person is a law enforcement officer (LEO) there on law enforcement business. Hospital security guards don’t carry guns. When a prisoner has to be hospitalized, the LEO guarding him/her would have their service weapon with them.

These days, with HIPAA, the patient/family would likely have to give permission unless the bodyguard works for the hospital as an employee. When someone is admitted to the hospital, they sign a blanket paper that allows hospital personnel to treat them—like nurses and X-ray techs. Still, he’s not going to be involved in patient care, so he’s treated more like an administrator—someone who may be in on patient-related conversations and must keep them confidential. It’s a potential liability for the hospital to have him in the OR if he gets hurt (ie, passes out and hits his head, for example). The hospital might hire him as an independent contractor and require him to provide his own liability insurance.
Chances are he’d be asked to station himself outside the OR doors—but there are two sets. Most ORs have a door to the main hall and a door to the supply hall (usually on the opposite side). Two doors to guard, in other words.
Assuming you cover both doors, you’d have to check ID on anyone entering the room. It’s amazing how much of a “disguise” scrubs and a surgical hat and booties provide.
3) During the operation, a poisonous gas is funneled into the OR through the ventilation.
Heroine passes out; the hero manages to get heroine out of OR before he passes out.
Would the hospital staff remove his weapon when then tend to him?

Yes, they’d remove it. Assuming he was taken to the ER, they’d remove the gun and lock it in the ER safe—unless another officer was there to take it into custody.

Questions? Comments?
~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it.

Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.
Like crime scenes? I recommend Crime Scene Writer. To join: crimescenewriter@yahoogroups.com

Pregnancy Complications in a Postapocalyptic World

My futuristic story is set in a post-apocalyptic primitive world, sort of like in the seventeen hundreds. No electricity. I have an eighteen year-old pregnant woman, and I need a complication of late pregnancy that is likely to kill her but not her child (who is the future hero).

Here are a few:
1) Eclampsia-- a condition of severe high blood pressure, kidney and liver issues. More common in first pregnancies, but can occur with any pregnancy. Very dangerous, and can be fatal.
2) Cardiomyopathy-- the heart muscle becomes weak during the pregnancy, and the woman goes into heart failure. It can happen with any pregnancy. Once it does happen, further pregnancies are not recommended.
3) Heart valve issues, especially narrowed heart valves (specifically the mitral and aortic valves). Rheumatic fever would be a cause of valve disease in a woman without access to antibiotics for a childhood strep throat.
4) High blood pressure in the lungs (pulmonary hypertension). This is most common in women between ages 20 and 40. It may be autoimmune. It causes terrible shortness of breath, swelling of legs, and patients can have a bluish color due to low blood oxygen. Pregnancy is not recommended in women with this problem, as it is often fatal.
5) Blood clots in the legs, breaking off and going to the lungs (pulmonary embolus). Can be fatal. A clot in the leg was known as “milk leg.”
6) Placenta forming over the cervix (the exit to the uterus). Known as placenta previa, it causes bleeding, and can kill both the mother and child.
7) Placenta pulling loose--bleeding, fetal distress. Known as abruptio placenta; the mother can bleed to death.
8) Failure during delivery: baby gets stuck coming out. As C-section wouldn't be an option, mother and child would both likely die.
9) Uterus won't contract after delivery-- severe bleeding. Can be fatal.
10) Twins, triplets-- higher chance of injury to or loss of the babies and the mother.
11) Breech birth-- baby tries to come out feet first. May get stuck, may have fetal distress.
12) Gallbladder disease-- more common during pregnancy. In extreme cases, a stone can get stuck and lead to pain, infection, inflammation of the pancreas. Death can ensue.
13) Appendicitis--an old fashioned killer, but not uncommon when medical care (especially surgical care) is not available.
14) Pneumonia--another old fashioned infectious disease that can turn fatal.

If you want something showy, plague is a possibility. Spread by lice in unclean conditions, this infectious disease scourged Europe in the Middle Ages. Infants sometimes survived when their mothers didn't.

Hope this helps clarify the situation. If you need more help, please leave a question in the comments!
Cheers, Kelly

Questions? Comments?
~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it.

Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.

Like crime scenes? I recommend Crime Scene Writer. To join: crimescenewriter@yahoogroups.com

Strangulation Part Two: More on Mechanisms

A couple of questions: when you set a scene where someone is being choked by an object around the neck or pushing against the neck - that death isn't immediately from that particular action, but rather it is the breaking of the hyoid and the swelling that results from it? So unless the garotte cuts through to the carotid arteries, this could be a much slower way to die?

What about people who go unconscious from lack of air? Is it possible they could also suffer from the hyoid breaking and not wake up after passing out? I'm just curious as to how alive a person might be in order to overhear his would-be killer's plan :)

Thanks ~ Killion

Hello, Killion!
The brain needs blood. A few seconds without blood flow causes unconsciousness. This is the so-called simple faint. You lay the victim down, more blood flows to the brain, and the victim wakes up.

After a couple of minutes--like in a cardiac arrest situation--the brain is starving for oxygen, and the cells can be damaged. Waking up is harder, takes longer, and the victim may have deficits.

Four to five minutes--and brain damage (enough to cause a vegetative state, as in organ donor) starts.

All of this just from lack of blood flow through the carotid arteries.

The initial stage of "strangling" is the result of the victim passing out from lack of blood flow. They're defenseless.

The perpetrator continues squeezing the neck.
Breaking the hyoid usually collapses the airway. There is immediate soft tissue damage and swelling. Now you have impaired blood flow to the brain and impaired oxygen in the bloodstream.

Lack of air alone won't break the hyoid. Strong hands--usually a man's hands--with thumbs over the hyoid is necessary to break it.

Passing out from lack of air--like at altitude (a small plane for example, or suffocating inside a plastic bag) is because of low oxygen. Defenseless victim.

If the bad guy strangled the victim just enough to cause a faint (there would still be a pulse and breathing) the victim could potentially wake up and overhear the plans.

Since the brain prefers glucose (sugar) as its food source, low blood sugar will cause passing out (example--a diabetic who takes their insulin then doesn't eat).

Hope this helps clarify the situation.
Cheers, Kelly

Questions? Comments?
~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it.

Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.

Like crime scenes? I recommend Crime Scene Writer. To join: crimescenewriter@yahoogroups.com

Strangulation—How it Works

In my scene, I want to have the villain strangle the victim, using a picture wire. The death needs to be very fast. Will this work?

A wire tends to cut into the tissue of the neck, and isn't very broad--it'd be hard to place it directly over the hyoid, especially if the victim struggled.
Most victims will grab at the wire, twist their body, trying to dislodge it—this is survival instinct. The arms won't be flailing. If the victim is off the ground, they may kick.
I can't think of any protrusion or modification of the wire that would be so effective so fast that the victim won't struggle at least a bit. A protrusion that angles upward toward the base of the tongue, which would jam into the bone, might work. Still, death won't be instantaneous.
Let me give you an example.
I’ve seen a drunk driver—not wearing his seatbelt—who rear-ended a parked pick-up. The guy wasn’t going that fast, but his vehicle was old and didn’t have air bags. He hit his throat on the steering wheel. He had some pain in his neck, but drove home. By the time he got there, he was more and more short of breath. He woke his wife, and she drove him to the ER. On the way, he began clawing at his neck, wheezing with each breath.
By the time we got him, he’d had a cardiac arrest; we had to cut a hole in his throat for him to breathe.

X-rays showed his hyoid was broken. BUT, what killed him was swelling in the soft tissue of the neck that progressed after he hit his throat. This is part of the mechanism of strangulation. Here's an illustration of the neck and location of the hyoid bone—that should help with visualizing the process.
Cheers, Kelly

Thanks to Connie for this question!
Questions? Comments?

~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it.

Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.

Like crime scenes? I recommend Crime Scene Writer. To join: crimescenewriter@yahoogroups.com