Putting the science in fiction - Dan Koboldt, Chuck Wendig 2018

Medical misconceptions, Part I
Research labs, hospitals, and really bad ways to die

by Karyne Norton

I haven’t been able to watch shows with hospital scenes for the last decade, and I cringe when I run into medical misconceptions in books. I wish I could ignore the errors, but they stand out to me like bad grammar stands out to an English teacher. My hope is to help writers who don’t have medical training get through some of the common pitfalls of writing about medical situations.

Misconception #1: CPR is for living patients

I can’t tell you how many times I’ve seen writers mess up cardiopulmonary resuscitation (CPR). One of the first things they teach us in Basic Life Support classes is that you can’t screw up CPR because the person is already dead. Your goal is to bring them back to life. But if the patient is talking, moving, or breathing, you should not be doing CPR.

Real CPR Training

If your character comes across an unconscious person and they have any medical training, here’s what they’ll do.

1. They’ll gently shake the unconscious person and call their name (or shout something) to see if they wake up.

2. They’ll ask nearby people to call for help/911. They also might ask for an automated external defibrillator (AED).

3. Sometimes (especially on children) they’ll check for breathing. It used to be taught as ABC (airway, breathing, circulation), but for strangers it’s no longer recommended to do mouth-to-mouth resuscitation, and recent studies have shown that circulation should be prioritized because our blood has plenty of oxygen to circulate without rescue breaths. Children tend to have healthy hearts, so if they’re unconscious it’s usually because they choked or drowned.

4. Most often they’ll immediately check for a pulse on the neck or wrist. If there’s no pulse, they start chest compressions. Real chest compressions look awful. If they don’t look awful, you’re not pushing hard enough. Bones break.

5. When an AED is available, they use it to shock the heart back into a viable rhythm. AEDs come with written instructions, but the machine also talks you through the steps to use it. Feeling confident with this machine could save a life, so don’t be afraid to read more about how they work: www.nhlbi.nih.gov/health/health-topics/topics/aed/howtouse.

6. They continue administering CPR until an ambulance arrives.

Figure 5.1: An AED

Keep in mind these are not the same steps used to revive a baby at birth. To accurately depict this, you’ll want to refer to the Neonatal Resuscitation Program (NRP) guidelines.¹

CPR in the Hospital

When a patient needs CPR in a hospital setting, the same general steps are followed, except when someone calls for help, they push a code button on the wall that alerts an entire team of medical professionals to come to the room with a code cart. This is often depicted as a chaotic moment, but in larger hospitals it’s more like a highly intricate dance.

The first person to find the patient is generally the one to do chest compressions. The next person to come will start giving oxygen through a bag and mask. If there isn’t already an IV, someone starts one. Another person sets up the code cart and hooks the patient up to the EKG monitor. Another simply records everything that’s being done at what time so they can chart it all later. Usually there are five to ten people that walk in within a minute (if not sooner).

When the anesthesiologist arrives, the person in charge of airway assists her while she gets the patient intubated (compressions are paused during this process). The patient’s primary doctor usually watches everything that’s being done and gives out orders. Others in the room are encouraged to voice any ideas or steps that might have been missed.

There’s a lot happening at one time, but don’t think for one second that it’s disorganized. The code teams in hospitals are trained to respond to every code in the hospital, and depending on the size of the hospital, there can be a handful each day.

Misconception #2: Babies fly out in one push

This is the absolute hardest one to please me on because it’s my area. If I love a book and a delivery scene shows up, I tend to skim it out of fear that I will forever close the book. Your personal labor experience is yours and probably shouldn’t be your character’s. If you barely made it to the hospital and your babies practically slid out, please realize it’s not common. According to the Centers for Disease Control and Prevention’s National Vital Statistics Reports, 23.8 percent of women were induced for their labor in 2015.² Many of those inductions last days. So your character will very likely have time to make it to the hospital. She will even have time to get to the labor and delivery unit so she doesn’t have to have a hectic and dramatic delivery in the emergency department, where they do everything possible to avoid taking care of a pregnant patient. The emergency department sends pregnant patients to labor and delivery even if the patient checks in for a broken toe.

Another 32 percent (there’s definitely crossover with the inductions) end up with C-sections.³ Yes, your character can have a C-section. It could even be planned. Your character can also have an epidural, and if she lives in present-day America, she probably should because about 90 percent of laboring Americans do. I’m sure your character is a very strong woman with a high pain tolerance, but that doesn’t have anything to do with whether or not she would get an epidural. And the women who don’t get epidurals? They don’t all scream bloody murder. Some don’t make a sound.

Misconception #3: IVS are needles

This is a pretty quick fix, but I see it often enough that it’s worth mentioning. When an IV catheter is inserted a needle is used, but the needle is immediately removed and a plastic catheter is all that remains. This is a common misconception among patients, too (especially ones who like to complain). Don’t have your characters notice the needle in their arm or complain about it being sharp. Or if they do, have your nurse character set them straight so you get a smile out of this reader.

Misconception #4: Meds are used to shut people up

This is incredibly illegal, and for some reason writers like to have their characters being given meds that knock them out left and right. “You have a scrape on your elbow? Here, let me start an IV for no reason other than to give you an incredibly potent narcotic that I happen to have in my pocket and I can’t possibly already have an order for. That way you’ll fall asleep super confused and the reader will want to turn the page.”

That’s seriously how I read those scenes. In the hospital setting, we need a physician’s order to give any kind of medication. Even oxygen requires an order. In emergency situations, there’s almost always a doctor present to give us that order, but we can’t just pull it out of our hat. Narcotics (and most other medications) are kept locked up in medication dispensers that require passwords and fingerprints to access.

We also have to get permission from the patient to give any medication. If a patient is in hysterics and needs to be restrained in some way, most hospitals have policies requiring two physicians agreeing that the physical restraints or medication (never both) be used. And these are very rare occurrences.

Now, I’m not going to lie. Medications get used to shut people up, but it’s usually done by the nurse strongly encouraging the patient to ask for the medication. Nursing licenses are too hard to earn just to lose over a stupid narcotic and an annoying patient.

Misconception #5: Teens get treatment without parental sign-off

Be careful what you have your young adult characters getting done without parental figures present. In emergency situations, minors are treated in order to save their lives. But pain medications won’t be given out to every crying kid. You may not always need parental permission to get an abortion, but if that same girl decides to show up at the hospital six to nine months later wanting an epidural, mommy or daddy might need to sign for her. Some of these issues are state-specific, so do your research. For example, in Arizona pregnant teens are considered emancipated and can sign for their care in labor and delivery. Once the baby is born they can sign for the baby, but they then revert back to needing parental consent for their own care.

How to get the medical stuff right

I’m only scraping the surface of medical misconceptions. Someone who works in an oncology unit or cardiac unit might have very different things to point out. Some medical standards vary regionally, while others are affected by specific hospital policies. So what’s a writer to do? Make a nursing friend. Or two. Or twelve. Honestly, we’re very friendly people and we love talking about our jobs. Just be aware that you might hear more than you want, and you might not want to eat while we talk.

1 American Academy of Pediatrics. “Neonatal Resuscitation Program.” AAP.org. www.aap.org/en-us/continuing-medical-education/life-support/NRP/Pages/NRP.aspx (accessed May 4, 2018).

2 Martin M.P.H., Joyce A., Brady E. Hamilton, Ph.D., Michelle J.K. Osterman, M.H.S., Anne K. Driscoll, Ph.D., and T.J. Mathews, M.S., Division of Vital Statistics. “Births: Final data for 2015.” National Vital Statistics Report 66, no. 1 (2017): 53.

3 Ibid., 53.