Putting the science in fiction - Dan Koboldt, Chuck Wendig 2018
Medical misconceptions, Part II
Research labs, hospitals, and really bad ways to die
By Stephanie Sauvinet
Popular medical shows are full of dramatic, emotionally draining situations such as a beloved primary character “flatlining,” or a poor child impaled by some foreign object. Often, these scenarios are overdramatized for maximum emotional engagement with the audience. Unfortunately for those of us working in the medical profession, it’s often difficult to look past the gross scientific and medical errors repeatedly shown that could be downright dangerous and life-threatening if performed on a living patient.
I find myself wondering if production and/or writing staff enlist the aid of medical consultants, or if the goal is simply to maximize the drama (at a cost of reducing the scientific accuracy). Anyone who has faced one of these scenarios “in real life” will undoubtedly tell you that these fleeting seconds are already packed with enough drama to last a lifetime. There is no reason to insert additional drama into the equation when a real person’s life is on the line; you already have Thor’s hammer pounding your chest. If you don’t want to end up with a dead/incompetent character, follow along.
Misconception #1: The defibrillator myths
Shocking a Flatline
Electrical signals are the enablers of a beating heart: They run through it creating the familiar “lub-dub” sound. The electrical pulses are unique to the heart and are created by three main bundles of specialized cells. Similar to the pistons in a car engine, the parts of the heart need to beat in a specific rhythm to pump blood effectively throughout the body and provide oxygen to your organs and cells through a process called oxygenation. A heart monitor is used to display the rhythm a person’s heart is following. The “rhythm” is another way of describing the behavior of the current running from bundle to bundle.
The purpose of a defibrillator is to “reset” the heart’s rhythm by disrupting (“shocking”) it—think CTRL+ALT+DELETE for a PC or COMMAND+OPTION+ESCAPE for you folks who like machines named after red fruits. If the rhythm isn’t appropriate to circulate the blood to the rest of your body, shocking it will hopefully “reboot” the rhythm to its normal (effective) rhythm by forcing the bundles to communicate once again in an organized pattern.
When a flatline occurs (also called asystole), no electrical current is running through the heart. If pulseless electrical activity (PEA), a condition that looks very similar to a flatline occurs, there may be a tiny bit of quivering occurring in the heart. This quivering is usually not enough to make the heart contract and the patient has no pulse. In these cases, shocking the heart won’t do anything. Remember that shocking only resets the electrical current’s rhythm and does not add or produce current within the heart.
So how do we add current to the heart? Think batteries! What creates current in a battery? A chemical reaction! Each electrolyte has a specific electrical charge, and their movements across various cells within the body create an electrical charge. That is why medications like epinephrine are administered. These medications will affect electrolytes within the body, forcing them in or out of a cell in an attempt to create current and “jump-start” the heart.
Only after the flatline or PEA event stops and we begin to see current within the heart can we begin to worry about whether it is beating in the correct rhythm. If the rhythm is not correct (based on the output of the cardiac monitor), defibrillation can be applied.
Rubbing the Defibrillator Paddles
A defibrillator uses either paddles or pads that are applied to the patient’s body. When defibrillator paddles are used, a conductive gel is usually applied to assist with conduction and prevent severe burns to the patient’s chest. While rubbing the paddles together may add to the drama, it is completely unnecessary because the gel will spread once the paddles are placed on a patient’s chest.
The most up-to-date cardiopulmonary resuscitation (CPR) guidelines prefer self-adhesive pads over paddles. The self-adhesive pads are placed on the patient’s chest and remain there for the entire duration of a cardiopulmonary arrest (or “code”). They help minimize any delay between pausing CPR, “clearing” everyone touching the patient (or “CLEAR!”), shocking the patient, and resuming CPR.
The self-adhesive pads also allow for heart pacing. After the shock is administered to the patient, the heart’s rhythm may be too slow to perfuse blood adequately to all of his organs. In these cases, the defibrillator can then be set as a pacer to provide additional shocks with just enough electricity through to pace the heart rate to a faster range.
A Patient Is Shocked, and Her Entire Body Lifts Off the Table
Muscular contraction and movement occur based on input from the “processing center” of the body: the brain. This is the reason why a patient’s body may jerk around during certain seizure episodes: The brain misfires, resulting in random muscle movement and sharp jerking.
In order for a patient’s body to completely lift off of a surface, many different muscle groups would need to simultaneously contract. The heart sits in the center of the chest, with its apex slightly to the left. As a result, one defibrillator pad/paddle is placed on top of the right chest and the other under the left breast, laterally. The purpose of this placement is for the shock to travel from right to left and up to down, following the same direction that current normally flows through the heart.
Current immediately ceases to be applied once it reaches the left pad/paddle. With the electrical current localized to this region of the body (and therefore only applied to a limited set of muscle groups), it is physically impossible for the person’s body to violently lift off the table.
Misconception #2: Injecting medicine straight into the heart
Very dramatic, but also very deadly!
The heart is a very fragile organ protected by a bone directly on top of it called the sternum. This biological construct should provide a not-so-subtle hint that attempting to access the heart in this manner is probably a bad idea. The vascular system is a closed system for a reason. Piercing the body’s main pumping station would result in an imminent death sentence by bleeding!
The only time a needle is used to pierce the heart, other than during major cardiac surgeries, is for a procedure called pericardiocentesis. The heart is enclosed in a double-walled sac called the pericardium. The sac contains a small amount of fluid that lubricates the moving part of the heart as it beats. Under the affliction of certain diseases, the pericardium sometimes fills up with too much fluid, creating a pericardial effusion. If significant enough, it can develop into cardiac tamponade. This extra fluid is life-threatening as it squishes the heart to the point where it is unable to beat efficiently. During pericardiocentesis, a physician uses a needle to drain some of the fluid to relieve the pressure around the heart using an ultrasound machine as a guide.
At the present time, the best way to administer lifesaving medication is through an IV placed by a medical professional. Outside of a hospital, you may not have an IV already in place. In these cases, a needle is used to inject the medication into a peripheral vein. Much like a blood draw, some type of tourniquet can be applied to help find a vein and the needle can be threaded in the vein to administer the injection directly into the bloodstream.
If an IV is not available during an emergency situation, medications can also be administered through intraosseous access (IO). This type of needle is inserted into the bone marrow of specific, highly vascular bones that cause the medication to be absorbed in a fashion similar to that of an IV access. It is extremely dangerous to access the sternum because the heart sits right behind it. Other bones are used for IO access such as the head of the humerus (shoulder area) or the proximal and distal tibia (right below the knee and above the ankle).
Remember: If medications are administered to a person who has no pulse, CPR should also be performed. In addition to being life-sustaining, chest compressions also help circulate the medication throughout the body.
Misconception #3: Pulling out foreign objects
Many fictional characters have pulled foreign objects out of the human body in a fit of rage/courage. This is another thing that looks great on the big screen (or in small print), but it might have the unintended consequence of ending our hero’s world-saving career! The arrow/pole/knife/other foreign object may be the only thing compressing a severed artery and slowing the bleeding down. As soon as it is removed, the hero may quickly bleed to death.
In these situations, the best course of action is to stabilize the object as best as possible and remember that movement may do more harm than good. After doing this, immediately seek professional medical attention to have the object safely removed (this usually involves surgery).
Get medical facts right
Social media is your friend: There are so many venues to start a conversation with someone “in the know.” Most people in the medical field, myself included, love to talk about what we do. Trust me, we’d rather stab ourselves in the eye than read a novel or watch a movie where false medical practices are propagated and facts, if they ever were facts, degrade into dramatic fiction. Strike up a conversation with us. Ask around; do your research before your pen hits the (digital) page!