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- Lecture: Medical Myths in NS
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| Lecture: Medical Myths in NS | |
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| Topic Started: Sat Dec 16, 2017 1:15 am (128 Views) | |
| Almonaster | Sat Dec 16, 2017 1:15 am Post #1 |
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Here is a recording of Themis's lecture. https://www.dropbox.com/s/65fiykpw8z2omx1/NS%20Lecture-WF17.mp3?dl=0 |
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| GThemis | Sat Dec 16, 2017 1:23 am Post #2 |
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Thank you kindly! Any questions are welcome by everyone. I've been asked for a transcript - sadly Dragon went on strike so transcribing it will be rather difficult. I'll post some notes I wrote below before procrastination kicked in as reference: s a medical professional, I unfortunately have a terrible habit that many of my fellow colleagues can empathise with: I am an awful person to watch any medical-related television with. I ruin any medical drama I watch with a scathing dissection of the terrible tropes, inaccuracies and cliches that are all too abundant in the world of cinematography. Some things are minor, some essential (if somewhat difficult to believe) for the emotion of the plot – but many lazy, terrible tropes find themselves diffusing into 'common' public knowledge, and from there, into the writing of many a role play. The aim of this lecture isn't to engage in a session of bashing poorly researched roleplays, nor is it pontificating that only medical professionals should dare write about anything medical. It's far too easy these days to criticise without offering any solutions. Instead, I hope to improve medical-inspired writing in NS RP by discussing some of the more common, inaccurate, even dangerous medical cliches that come up time and time again in NS writing, and compare them with what actually happens in reality. To conclude, I hope to provide direction to resources that can help with writing. – 1 – The Lazarus Complex In fiction and reality, one of the most emotionally charged events is the death of a character, and the desperate efforts to bring them back from the brink. Whether it's someone desperately pounding on their chest to restart their heart, the kiss of life between two romantically involved characters, or rigging up a car battery and two jump leads; the desperate attempts to preserve life are poignant to reflect on in great writing, though more often are a convenient way to resurrect a character. Depictions in fiction though, especially on screen, can be lazy, or downright dangerous. And of course, this eventually a. CPR Myths In researching for this lecture, I found a fantastic article on the subject of medical tropes. Amongst them, their description of CPR as 'Clean, Pretty and Reliable' was very much a cutting criticism of how the act of resuscitation is portrayed in literature. Take the stereotypical, relatively family friendly drama – where a brief pound on the chest, romantic locking of lips plus or minus some suspension of disbelief, sees our character sitting up ready to go from where they left off. The reality is anything but. In hospitals of all places, CPR is deemed as successful in 17% of cases, based on UK statistics from 2015. Outside of hospital, that quickly drops below 10%. By success I should clarify we solely mean staying alive long enough to get home from hospital. A percentage of this number will walk away from CPR without long term complications. For certain types of cardiac arrest, this rate is even lower. Before I rant, I should explain what cardiac arrest is, and the point of CPR. Most importantly, it's a state we try to avoid as much as we can, through rapid intervention by highly trained professionals as soon as we can; once your heart stops beating effectively, as mentioned, it isn't easy to restart it. In essence, we consider the absence of a central pulse (and thus blood pressure) as incompatible with life, and consider such a state cardiac arrest. This can be preceded by eight or so broad categories of malfunction, all of which have this end result. Without blood pressure, blood does not perfuse into end organs, be that the brain, the heart itself, or any other organs. Within 3 or so minutes, that lack of perfusion, with all the oxygen that blood carries, leads to permanent and irreversible damage to the brain, and an inability to bring that person back from death's doorstep. Hence, our initial aim (basic life support) is to get that blood pressure up, through high quality compressions of the heart through the chest, and/or get some oxygen into the blood through artificial ventilation. Aim number two is to correct whatever has caused the cardiac arrest, with the aim of restoring heart function to that compatible with life (Advanced Life Support). Part of that involves examining the heart's rhythm and applying electricity and drugs accordingly (discussed later), the other part is identifying exactly what caused them to end up in this state, and treating it to both restore circulation, and prevent further cardiac arrests. Now as to the act of CPR itself. Compressions at a rate of 100 to 120 per minute, to a depth of around 5 centimetres, in the lower third of the sternum, 30 repetitions to 2 ventilating breaths, checking for signs of life every 2 minutes. A basic skill that should be taught to everyone at school, and kept up to date as an adult. On the plastic resusci-anne dolls, and on the silver screen, it's clean, straight forward and pretty. The model clicks a bit as you start pounding away at the chest, arms locked as instructed as you let your body weight drop onto the chest and bounce back up. And miraculously, they come back to life. Don't bend your arms like they do on TV – they only do that so that the actor doesn't come away from the shot with broken ribs! I'll admit that I was under that illusion when I first had to do CPR in anger. I'd just be straight forward, that they might even wake up afterwards. Of course it wasn't. The man in question had collapsed at work after coughing up a cup of blood. Within a couple minutes of arriving, he became awfully quiet, and which point we realised he had no pulse. With the first compression on his chest by one of the nurses, he vomited violently, cueing a minute of panic from me as I tried to suction his airway. All the time, above the hiss of the oxygen and the loud buzzing of the vacuum pump, the creaking of the poor man's ribs. Then I swapped on to his chest, and soon enough I felt my hands dip into the crater the last two of my colleagues had left on his chest, where the ribs had given way, even fractured. In a way it was a positive – I didn't need to think about my hand placement as much as I moved away, and I didn't need to feel the initial sickening groan of the ribs giving way. What happens when you are successful though, in that minority of cases? Well, it isn't all over. Firstly, whatever caused the heart to stop functioning effectively, that doesn't go away with the heart starting again. And if it isn't fixed, you're back to square one. It's difficult to work out how much damage has been done by the lack of heart function – but often, brain injury, seizures, persisting injury to the heart and other organs, all may risk being present. And of course, it all depends on the person. A young, fit soldier, as per the standard military writing that is the mainstay of these forums? They may be back to the point they can leave hospital and convalesce at home within a few weeks to months. They certainly won't be up and back in the fight as they take a massive gasp of air, all fit and ready to go. An elderly, frail widower who couldn't cook for himself before this event? It's unlikely he'll ever leave hospital. Reflecting back to the previous gentleman, who as part of the emergency team, I participated in his resuscitation. Almost miraculously, after 10 minutes of chest compressions, he had a pulse – and not only that, a strong, good going pulse. Fantastic, we thought at first. But of course, the underlying problem was still there, and he had yet to show that he could breath for himself. A lesion from tuberculosis that riddled his lungs had eaten into one of the pulmonary arteries, puncturing it and filling one side of his chest with blood. We had guessed as much from the examination we performed, and had our suspicions confirmed on X-ray. But then what? A chest drain and six months of intensive antibiotics, in lungs that would never truly recover? Months on intensive care and a ventilator, with the chance he would never come off? Due to circumstances, I never found out what became of him. I hope, however naively, that it was a happy ending. From this, I hope to guide you the audience, in how to approach this subject. Rather than approaching it as a quick and lazy plot device to magic a character back from the bring, or some cheesy attempt at romance that borders on sexual assault, I feel that one would do well in considering this as what it is – a last ditch attempt at bringing someone back, when all other treatments to avert this have failed. Put yourself in the shoes of the person or team trying to bring them back. For the bystander or newly initiated, its an experience of pure terror and desperation. Of course, it may be more successful more often that it is in reality – after all, this is fiction, and stories where the hero dies tend to be far more difficult to bring to a satisfying end. And to everyone who may one day be put in the situation of having to do CPR – I don't mean to write this to put you off, merely to prepare you for reality. Some people might consider this as offputting for people wanting to help those in cardiac arrest – indeed, the idea of compression only CPR (no need for mouth-to-mouth) is based partly on that. I feel that the tiny minority people who would rather watch someone die after this, than assist as taught in such a situation, should really look at themselves in a mirror. b. Defibrillators and Monitors And so we come on as promised to the magical electric box that is the defibrillator. Do we know what it actually does? Surveys say the majority of people think, incorrectly, that judicious application of electricity to the heart will make it start again. And indeed, after playing a game such as Battlefield 2, or watching some of the more poorly thought out scenes on the big scene, they make a convenient get-out-of-death-free device. In the real world, a defibrillator is used to terminate abnormal heart rhythms. By applying a single, powerful burst of DC electricity to the heart, the entire organ depolarises, essentially giving it a fresh slate to start up again from scratch properly and terminating abnormal beats. And we're talking a fair amount of electricity here – enough if improperly applied to stop the heart of someone carelessly in contact with the patient. Only around 16% of cardiac arrests present with a rhythm that would be fixed with a shock (Ventricular Fibrillation and pulses Ventricular Tachycardia, for the more medically minded amongst you), at which point we fire first and cross our fingers that after a further two minutes of chest compressions, they get a pulse back. So, looking at that little screen as we dramatically rub the paddles (discontinued in most places due to burns and other horrible accidents), our eyes are drawn to the rhythm the heart is beating out. The heart can still have electrical activity and not be functioning properly. And, surprisingly enough, it isn't a totally flat line. Indeed, a perfectly flat line normally suggests that a lead has fallen out of the machine. Instead, there's a gentle rise and fall of the patient being ventilated, with the occasional 'agonal' attempt from the heart to get an electrical signal. d. Other CPR myths I'll whistle through these at whistle stop pace. Adrenaline does not get injected directly into the heart. I cringed incredibly hard when I saw them do that in Pulp Fiction and the remake of a Nightmare on Elm Street. If we go back to the 1950s, in a patient with no venous access, a hospital with a fraction of the drugs and means we have today, and the mindset of 'well they're dead, we can't make them any worse', then it might be acceptable. Indeed, I see reference to it in the 1957 British National Formulary. But these days, for very good reason, we don't. Why I hear you clamour? Well, studies remain ambiguous about whether or not adrenaline has any real benefits in resuscitation. And you can cause injury to the arteries of the heart, alongside leaving a nice hole for blood to leak out from, causing tamponade and another cardiac arrest down the line. Don't confuse this with the adrenaline in an Epi-Pen for anaphylaxis, which most certainly does have benefit, as does adrenaline used in hundreds of other circumstances. Epi-pen adrenaline (1:1000) is ten times more concentrated than adrenaline used in resuscitation (1:10000), and if given in a vein (or direct to the heart), can either cause the heart to develop irregular rhythm and stop functioning, or cause such profound construction of veins and arteries that you cause total cut off of the blood supply (including the arteries supplying the heart). Hitting the chest with a fist, or downright bitch slapping someone, will not fix them. And for the real world... Anyone can do CPR. Of course it helps to have someone with medical training there, but that shouldn't stop you. Take a short course (they're often free these days). And you don't have to lock lips if you don't want to. === 3 – Someone sneezed in Madagascar... A recurring plot theme on the Nationstates forums is the dodgily written plague as a plot device. Invariably it's 100% lethal, spreads super fast, and is totally incurable. Except for the person deploying it. And course, there is terror in it.... Common misconceptions though... > How contagious (or non-contagious) things are > How incurable things are > How stereotyped things are And that's as far as I got... feel free to ask any questions, both here and to TG. |
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| Sanctaria | Sat Dec 16, 2017 1:27 am Post #3 |
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I really enjoyed this lecture - hopefully we'll see it improve many RPs! Thanks Themis! |
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| Zazumo | Sat Dec 16, 2017 3:29 pm Post #4 |
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Really interesting stuff, glad I listened :) |
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| Palos Heights | Sat Dec 16, 2017 5:30 pm Post #5 |
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Thank you for this lecture! As a fellow healthcare professional over here in the states I think one of the major problems that plagues issues in NS with regards to the quality of medical-related issues or writing in particular is a dearth of healthcare workers who get involved in writing. (That being said I know for a fact one of the editors is a HCP). But thank you for tackling this topic! Medical tropes and myths are abound and I frankly put the blame on the continuing propagation of these tropes on TV and movies that focus on healthcare settings. [Side note, I do find ER refreshing since it is arguably the most accurate among medical media considering its creator and writers were all physicians (RIP Michael Crichton).] Regarding a question I had, I was curious about your point regarding the efficacy of epi during a cardiac event being ambiguous. As far as I have thus far heard that wasn't so much the case but I would love to read any literature you have off-hand regarding the topic for my further study. Once again, thank you for this topic as it is sure to help people moving forward in their writing and understanding of how medicine works! Cheers, Palos Heights, PharmD |
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| GThemis | Sat Dec 16, 2017 7:40 pm Post #6 |
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Thank you for your question! The first thing to note with epi-pens is the adrenaline/epinephrine is at 1 in 1000 concentration, for IM use. The 1:10000 used for IV, whilst a ballpark similar dose may be used, is given at lower concentration to prevent vasospasm and ensure circulation. Adrenaline 500 micrograms still remains as one of the two drugs used in CPR (the other being Amiodarone 300mg) as per the European Resuscitation Council. In theory the inotropic effect and the vasoconstriction help maintain blood pressure. However, there is little data on the subject. As I recall, there was a trial in one of the Scandinavian states looking at the comparison between saline and water given during resuscitation, and finding no difference in survival to hospital discharge, despite some short term effect on chance of return of spontaneous circulation: https://www.resus.org.uk/research/other-research/adrenaline-versus-placebo/ How they got ethical approval I have no idea... In any case, if we're going to give it, then it's IV or IO only, since it's better to give it than nothing at all, until strong evidence proves otherwise (after all, they're already day!). Given every 3-5 minutes in non-shockable cardiac arrest, in shockable arrest given after the 3rd defibrillation. Injections to the heart as per certain films, well off. Epi-pens with said 1:1000 adrenaline... again not sensible for cardiac arrest, with the issues mentioned about concentration. Hope that clarifies things. |
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