Murder and Mayhem (11 page)

What Medical Emergency That Required Quick Action Would Likely Occur in a Gunshot Victim in a Hospital ICU?

Q: I'm writing a scene in which a paramedic is contemplating pulling the plug on a critically ill bad guy in the hospital ICU. Just as he decides to do so, however, the bad guy (a gunshot victim, by the way) suffers some kind of life-threatening emergency (cardiac arrest?), and the paramedic, acting strictly on impulse, performs some form of medical heroics to save the guy's life before hospital staff can reach his room.

Can you suggest a viable set of circumstances to fit such a scenario? What type of life-threatening emergency would specifically fit the bill here, and what could our paramedic do to avert disaster in the fifteen or so seconds it is likely to take the staff to respond to the situation?

A: A cardiac arrest would be perfect. Sudden and intense, it can be remedied with a single quick response. The paramedic could be at the bedside, contemplating his actions, when the monitor above the bed shows a sudden change in the intended victim's cardiac

rhythm. It can be either ventricular tachycardia or ventricular fibrillation. An alarm would sound in the room and at the nurses' station. The nurse watching the monitors at the station would see the same tracing, recognize the need for emergent intervention, and immediately a Code Blue would be called over the hospital speaker system: "Code Blue, ICU 3! Code Blue, ICU 3!"

The Code Blue team typically consists of ICU and/or ER nurses, the ER physician or any M.D. on the floor, a respiratory technician, and other ancillary personnel. They race to the room with a "crash cart" that has all the medicines, IV fluids, portable defibrillator, and so forth, needed for a resuscitation.

Meanwhile, the paramedic could act. A portable defibrillator unit would likely be at the bedside. He could grab the paddles, place them on the patient's chest, and fire away. The single shock could immediately return the person's rhythm to normal so that when the nurses and others arrived, the crisis would already be over. The doctor would then examine the patient and request an EKG, lab work, and other items in an effort to figure out why the event occurred.

Another possibility would be to have another Code Blue going on down the hall or in another ICU cubicle. Maybe when the victim's cardiac arrest occurs and the alarm goes off, a young and inexperienced nurse or a nurse's aide can run into the room and say the code team is tied up. He then can enlist her help (this would give you an opportunity for some interaction or dialog if that works for you), or he tells her to get one of the ICU nurses from the other Code Blue. After she runs out of the room to get help, he realizes he can't wait and must act now or the man will die.

This would be a likely real-life occurrence. I remember one wild night as an intern when we had three codes on the same floor at once. To say the resources were stretched thin would be an understatement.

What Information Would Emergency Department Personnel Give Out Regarding a "John Doe"?

Q: In my current novel my character's husband is missing. She calls the hospital, which informs her that there is a John Doe there matching his description. She immediately goes to the hospital to take a look.

My questions: Would they mention over the phone that they have a man fitting her husband's description? Is there a procedure for her to see and talk with this person, or would she just be allowed to take a look?

A: I assume that the man would be injured or unconscious or amnesiac or confused. Otherwise, he could tell them who he was and give permission to notify his wife. The police may be present in such a circumstance, especially if some sort of trauma is involved.

The charge nurse or the emergency room (ER) doctor would likely tell the caller that there was a John Doe in the ER but wouldn't give too many details—nothing that would violate patient confidentiality. But since the ER personnel and perhaps the police don't know who the person is and would be trying to identify him, anyone who could do so would be helpful. They would likely ask that she come to the ER.

When she arrives, the nurse or the doctor would probably let her see the victim. Remember, the doctor is responsible for the man's care, and he would want all the information he can get. Having a family member or friend identify the victim is a huge step in that direction. He could then ask about the victim's past medical history, allergies, current medical problems, current medications, and so forth—in other words, the things he needs to know to care for the patient.

What Medical Expertise Would a Seasoned Commando Possess?

Q: I have a character who served as a commando in the Israeli special forces and was specifically trained as a medic. He spent time in war zones where he carried out medical treatments for which he was not officially trained. His strategic skills quickly gave him an international reputation for planning and executing daring raids, rescues, and so on. While I rarely use his medical skills in the stories, I want to be accurate when I do. It seems he would be midway between someone with Boy Scout or Red Cross first aid skills and a medical doctor. Realistically, what would be the limits of this man's medical abilities?

A: His medical skills could be almost any level you wish. His abilities would be at least those of a well-trained paramedic. He would know CPR and how to handle many types of emergency situations. Since he served as a combat medic, he should be able to perform the initial treatment for all types of war injuries—wounds caused by gunshots, shrapnel, knives, explosives, and others. He would be adept at controlling bleeding, maintaining an airway, stabilizing fractures, and suturing most superficial lacerations. His biggest asset would be his grace under fire. When faced with any serious injury or emergent situation, the first step is to avoid panic and use common sense. That goes for M.D.s, too. He should be well equipped in this regard.

If you avoid the temptation of allowing him to perform sophisticated surgeries and treatments, you should be okay regardless of what he does.

Can Firefighters Estimate the Survival Time of a Victim Trapped in an Airtight Enclosure?

Q: An amateur illusionist walls himself up in a very small space in his basement, assuring his wife he can free himself without assistance. Naturally, she calls 911 so that rescue personnel can get him out. My question: How would firefighters arriving on the scene estimate how much oxygen he had left in the enclosed space? Is there a calculation they use based on the space in cubic feet, the height and weight of the trapped individual, and other information? If he was a diabetic and forgot to take his insulin with him, how would this complicate the situation?

A: Estimate? Maybe. Calculate? No way. This situation is much too complex. Let me explain.

First, the physiology. In the simplest of terms, the lungs take in air, transport oxygen (O
₂
) from this air into the bloodstream, remove carbon dioxide (C0
₂
) from the blood and exhale it back into the environment. This simple process is actually very complex and requires good air, good lungs, a good circulatory system, plenty of red blood cells, and a ton of chemical reactions. The diseases that can interfere with this process are numerous. In your scenario, however, we are dealing with a healthy person who has normal lungs and other criteria.

Unfortunately, that doesn't simplify the calculation very much. Let's take a glimpse at just how complicated such a calculation can be.

I'm sorry, but the metric system must be used here. Remember that one meter (m) is about 39 inches (3 feet 3 inches) and equals

100 centimeters (cm). A cubic centimeter (cc) is a measure of volume. One cc is a volume that is 1 cm
X
1 cm
X
1 cm.

Air at sea level is 21 percent oxygen.

An airtight room that is 3mx3mx3m (roughly 9 feet on all sides) would contain 27 cubic meters (or 27,000,000 cc) of air and about 5.67 cubic meters (5,670,000 cc) of oxygen.

A normal breath is about 500 cc. However, about 30 percent of each breath never reaches the alveoli (air sacs) and thus isn't involved in gas exchange (the passage of oxygen from the lungs into the bloodstream). This is the air that fills the bronchi (breathing tubes), which is termed the "anatomic dead space." Thus, 70 percent of each breath is potentially useful. Since an individual at rest breathes approximately 16 times a minute at 500 cc per breath, these are the calculations:

Total air intake = 500
X
16 = 8000 cc "Useful" air intake = 8000
X
70% = 5600 cc Oxygen intake = 5600
X
21% = 1176 cc

A person at rest therefore inhales about 1176 cc of oxygen per minute. This means that the oxygen in the room would last about 4821 minutes, or 80 hours (5,760,000 divided by 1176).

It seems like a long time to survive in an airtight box, doesn't it? It is.

These calculations assume that the person could use every cc of oxygen in the room. Not so. Remember that with each breath the percent of the air that is oxygen drops, and the concentration of carbon dioxide rises. By the time the O
₂
concentration fell to 15 percent or so, the person would be in severe trouble. This means that only about 6 percent (21 minus 15) of the oxygen content can be used to calculate survival time. And, of course, the mounting CO
₂
level compounds the problem.

When you add to this the fact that bigger people have higher 0
₂
requirements and that any activity, even standing or walking, increases 0
₂
usage, the calculations become extremely complex. And we've considered only the basic physiologic components of this situation. There are many others that are simply too intricate to explain. So even though these calculations can be done, they are not easy and cannot be performed by firefighters trying to save someone.

As you can see, this is a nice exercise in math and physiology, but it doesn't really answer your question.

When the rescue personnel arrive, they would be faced with an emergent situation where every minute counted. Rather than employing complex mathematics to calculate the time left, they would use signs and symptoms to determine how much trouble the victim is in and make a guess as to how fast they must move.

What we are talking about here is called "hypoxia" (low oxygen content in the blood). The symptoms and signs of hypoxia are similar to those of alcohol intoxication. The symptoms might include fatigue, lethargy, giddiness, headache, drowsiness, blurred vision, delusions, hallucinations, sleep, coma, and death. The signs would be loss of attentiveness, poor coordination, slowed reaction times, poor balance, rapid breathing, weakness, and finally collapse. These can occur in any combination and progress as your amateur magician consumes more and more oxygen and his hypoxia worsens. These should give you plenty to work with in constructing your scene.

Your firefighters would assess the person to determine how far along in the process he is. If he is giddy and confused, they would have more time than if he is in a coma and barely breathing. The first thing they would do is try to break open the chamber, but I assume that in your scene this isn't going to be accomplished easily. Short of that, they would attempt to bore a hole through which they can pump oxygen and buy some time.

The addition of diabetes to the situation would greatly complicate things, but only if the person is an insulin-dependent diabetic. Diabetics who are insulin dependent manufacture little insulin

themselves and must depend on the injection of insulin for survival. Missing a dose can result in a rapidly rising blood sugar level, the onset of diabetic ketoacidosis (DKA), coma, and death.

The symptoms of rising blood sugar and impending DKA are fatigue, shortness of breath, nausea, lethargy, somnolence, confusion, and finally coma and death. The person may become irrational, delusional, maybe combative and angry, and even have hallucinations. As you can see, the symptoms of diabetic ketoacidosis and hypoxia are very similar. Diabetics have been arrested for DUI because they were driving erratically and failed a field sobriety test, only to be found later to have diabetes.

The combination of low oxygen and rising blood sugar is additive so that the symptoms and the danger level progress much faster. This is more pressure for your firefighters and a true ticking time bomb. They now have to get oxygen and insulin to him and have less time to do so.

Perhaps they could open a hole and supply oxygen, but by then he could be too far gone from his diabetes to follow instructions or give himself insulin. The opening would be too small for anyone to get through to help him, and something might prevent them from making the hole bigger. A gas line? Electrical conduit? Steel beam? Wall cave-in?

Cool stuff. Just when it seems to be over, it isn't.

Can Paramedics Determine If an Accident Victim Is Alive by Measuring Liver Temperature?

Q: I read somewhere that paramedics can use some type of apparatus to do a liver test and determine if an accident victim is alive or not. What is this test?

A: Paramedics use vital signs (blood pressure, pulse, breathing, consciousness) to determine if someone is alive, dead, or in transi-

tion. If these signs are absent, they begin cardiopulmonary resuscitation (CPR) and ask questions later.