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A Crash Course in Anaesthesia and Intensive Care for (Sherlock) Fic Authors

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INTRODUCTION

I have been very positively surprised countless of times how well the non-medical professional fic authors in our fandom have tackled the technicalities of medical science. However, several very understandable misconceptions, clichés, stereotypes and false assumptions keep popping up. Most of them are due to the fact that someone who hasn't worked at an ITU can't reasonably be assumed to know these things, and some stuff can easily be blamed on TV and movies. I hope that this (incompletely, subjective, polemic and hopefully even slightly amusing) list of observations is of use to fellow authors. I'm happy to answer questions, so keep 'em coming. On the side of sharing information, I'm going to be mentioning Sherlock fics in which certain subject matters are discussed. If someone wishes to see a very well-done depiction of intensive care, I'd recommend watching season three of TV drama The Fall.

Before we begin, I want to say this: even though I rant and rave don't worry about the details and getting everything right. When I read Sherlock stories, I easily forgive even big blunders by non-medpro authors. Not your division. If you tell me a lovely story, I won't care if you mix your CVCs with your FBCs.

 

DISCLAIMER

This is not a medical textbook. Many things have been simplified and corners cut. The purpose of this is to provide ideas and resources for writers of fanfic, not medical advice.

Medical practices vary between countries and even hospitals within the same country. Terminology varies in the same manner. I try to stick with UK versions, which is kind of a bummer for me, since I live and work and was medically educated in Scandinavia. If a UK professional finds an issue with something here, please drop me a note so we can improve on this together. Also, while my medical licence says that I'm a Specialist Consultant in Anaesthesiology & Intensive Care, my days as an intensivist are over and it is most decidedly not my subspecialty or my strongest suit within this specialty. As a final word: this was written for the purposes of fic research, not as medical advice for actual patients. This is thus not a complete list of everything that happens to people at ITUs and does not apply to all possible cases. What this is, is a list of possibilities. Think of it as a smorgasboard of potential medical H&C. What you're writing is fic, not an information leaflet. I'm trying to give your imagination wings, not cut off its legs. If something here catches your fancy, do some googling. Many people have explained these things in more detail (and probably better than me).

Those who have read my stories know that I do not make light of serious things in them. Here, however, I will try to keep the tone light enough since we are not talking about individual patients, fictional or real. Intensive care is an intense, dynamic, fast developing and emotionally demanding field of medicine, and I have the utmost respect for those of my colleagues who have chosen it as their path.

That being said, let's crack on!

 


 

 

SOME MISCELLANIOUS GENERAL ISSUES ABOUT INTENSIVE CARE

 

Which patients need to bed an an intensive care unit (ICU/ITU)?

Intake criteria can vary, but the main principle is that patients who have a severe disturbance in one or two organ systems need to be at an ITU. A regular bed ward usually doesn't hook patients up to continuous monitoring, and they can't spare a nurse to sit by every patient's bedside. If a patient needs constant watching over, for instance if they're delirious and in need of sedation, they might also end up at an ITU. Some patients might not have a severe organ dysfunction yet, but they're at a risk of developing one. Examples: epiglottitis threatening to close down a patient's airway, an internal organ injury that looks like it could be just observed while it limits itself, but needs to be monitored in case there's a sudden rupture. Anyone who needs to be hooked up to a respirator usually goes to the ITU. Anyone who acutely needs dialysis usually taken into the ITU. To summarise: all the severely injured and critically ill patients go to the ITU.

One thing that often seems to baffle writers for fic, original fiction and TV and movies are altered states of consciousness. The general rule is this: if a patient's Glasgow Coma Scale is below a certain level (usually 9), their airways need to be secured to protect them from aspirating stomach contents and to control their carbon dioxide levels. Regardless of the reason for being out of it, if someone is unconscious enough, they can't be assumed to look after their own breathing and/or not inhale their own vomit. They need an intubation tube down their throat, and that also means that they need to be hooked up to a respirator. 

Not all critically ill patients will be admitted to the ITU. Often, the decision is brutally hard to make. The patient's chances of recovery from their current illness is largely dictated by their health prior to them contracting their current injury or illness. Age is not the sole deciding factor. Hopeless cases do not belong at ITUs. The number of spots at the ITU are not limitless; they need to be given those who will benefit from them. It is also unethical to prolong someone's suffering with intensive care, if there is no hope of recovery.

Here's a nice, detailed article on how to select patients to be admitted. Here's a flowchart from a London hospital that helps with such decision-making.

  

What sorts of doctors work at an ITU?

This varies. In some units, anaesthetists/anaesthesiologists run the ITUs and the other docs just act as consultants. At some units, a pulmonologist/respiratory therapists sorts out their turf, but the consultants from different specialties handle the rest of patient care. At some ITUs, anaesthetists and internists (or some other specialists, depending on whatever sort of an ITU is in question) work together to run the unit.

There are many sorts of ITUs. Some are generalised ones, where you might find all kinds of patients from head injuries to diabetic ketoacidosis. Some ITUs are just for surgical/trauma patients, some of just for neurological and neurosurgical patients. Kids usually get their own ITUs and so do neonates. Pick whatever option suits your story best, or have a look at a suitable hospital's website. They usually give some general idea on what sorts of patients each ITU unit handles. This largely also dictates what kinds of doctors work there.

 

What other staff does an ITU require to function?

Never forget that an ITU would instantly crumble without a legion of other (medical) professionals! Nurses, physical therapists, technicians, IT experts, laboratory technicians, pharmacology experts, cleaning and other maintenance personnel, imaging technicians/radiology nurses…

There are patient care assistants/ nursing assistants who help with moving and washing patients among other things. Quoting a commenter: "Depending on the nature of the ICU and the patients cared for there, there may also be a 'turn team' who will assist in the rolling of patients for pressure area care (PAC - it even has its own chart in the record in a lot of hospitals). Patients with spinal injuries or significantly difficult to manage injuries/ multiple drains or the like will need several pairs of hands to log roll/ wash/ change/ moisturise them safely and you cannot pull all the ICU nurses at once to do this." 

 


      

The downsides and risks of intensive care

Intensive care is invasive and risky business. While it can save lives and limbs, its very nature also creates risks for complications.

Prolonged bed rest, infections and many others factors present in this patient population give them a heightened risk of blood clots. They're often injected with blood thinners, or if that isn't possible, then pump socks or some other similar system is used.

Patients on a respirator are at risk of ventilator-associated pneumonia. All the other cannulas and hoses running into their bodies carry a risk of introducing bacteria into their bladder, their bloodstream or wherever than hose goes into. A respirator is never as good and natural a manner of breathing as what the patient does themselves with their own muscles and lungs. Bits of lung sacks might collapse due to not being inflated enough. A respirator might blow up the patient's lungs a bit too heavily, stretching the lung structures and causing microdamage.

Patients who need intensive care for a long time will lose muscle mass and joint flexibility. They are at risk of developing things such as intensive care polyneuropathy, intensive care myopathy and post-intensive care syndrome.

Intensive care poses a risk for developing a stress ulcer in the stomach or the small intestine. There are medications that can be used to prevent this. In Kourion's Shadow Child, a very complicated stomach ulcer is what lands Sherlock in the hospital and in emergency surgery.

Getting really ill is a big crisis for the patient and their loved ones (admit it: this is part of why you're writing about it, because of course it is, why else would we want to get one of our characters stuck at an ITU if it weren't for the angst of it?). That crisis doesn't end when they're carted off to a regular ward. Particularly those patients who have needed intensive care for a long time and who have been conscious at least for some of the time are at risk for an acute traumatic crisis reaction, even PTSD.

Even during an ITU stay, patients might experience a lot of psychological problems. ITU delirium is a major issue, and it doesn't always present as active restlessness.

 

What if a patient at the ITU is not getting better?

If the situation is judged to be medically hopeless, care will be withdrawn. It is not humane to keep patient suspended between life and death if there is no hope of reasonable recovery. Often the solution is to create a tracheostomy which will allow the patient to be moved to a regular ward. All the treatments that help them feel comfortable will be continued, but stuff associated with intensive care will be ceased. Antibiotics for a new infection might not be given anymore. Surgery will not be undertaken. Death is allowed to happen. Often that happens at the ITU, since these patients are often so critically ill that withdrawing some measures of care will result in their demise quickly. Some patients will live for days or weeks after being transferred out of the ITU. The decision-making in this sort of a situation is case-based and individualised and the wishes of the patient and their loved ones need to be taken into consideration.

I really liked the way the decision-making process and the associated extreme anxiety it causes all involved was discussed in Raison D'Etre by AmphigoricSymphony & DemonicSymphony.

      

 

What kinds of surgical patients are taken to the ITU from the operating room?

In general: patients who have just had cardiac surgery, major neurosurgery, major emergency surgery whether that be for trauma, abdominal organ disaster or something else equally severe. Patients who have had a major complication during surgery such as major bleed or anaphylaxis. Patients who were very ill before surgery and continue to be that way.

There are some situations in which interventional radiologists (ie imaging doctors trained to do procedures such as fixing brain aneurysms by slithering in stents and other nifty things through the patient's vascular system) can do wonders, but for acutely life-threatening surgery the trend tends to be that the procedures are not done via small scope holes. When you gotta go, you make a properly big opening. That's why the small dressing we saw on Sherlock in HLV was impossible. He coded, likely from a massive lung or heart injury or injury to a major blood vessel. When that happens, the chest needs to be cracked open properly. If you're not squeamish, do a google image search for "thoracotomy wound" and you'll see what I mean. The suffix –otomy point to a major opening somewhere in the body. A laparotomy is where you open up the stomach if, for instance, the abdominal aorta has ruptured or a patient's bowel has twisted around itself. The suffix –ostomy point to a minor incision into the body, most often for a drain.

A craniotomy is what you do if the brain needs to be operated on. That might be needed for a tumour, a major ongoing bleed or something else that can be taken away to fix the rising pressure inside the skull. A brain aneurysm might also require open surgery if the radiologists can't fix it. This is what Sherlock underwent in The Road of Bones, and craniotomies are what he does with John in the You Go To My Head series.

If the brain is critically swollen, and nothing else helps, a decompressive craniectomy might be undertaken. It means cutting out a section of the patient's bony skull to relieve pressure.

    

Worst cliché pet peeves seen in TV and movies and books (and yes, fic) when it comes to intensive care?

  • patients normally ineligible for ITUs being taken in
  • permanent coma patients "living their lives" at an ITU
  • prolonged intubation with no consideration for a tracheostomy
  • deeply unconscious patients without secured airways
  • critically ill or injured ITU patients without an arterial line and with just one smallish regular IV
  • the sound of the respirator being heard in the background when the patient isn't hooked up to one, or the respirator monitor shows curves in this situation
  • stuff on the monitor that isn't being monitored
  • saline and oxygen as cure-alls for everything
  • old-fashioned x-ray boxes - imaging is all digital nowadays (nearly everywhere)
  • the fact that they gave Sherlock a morphine infusion in a regular infusor pump in HLV; it probably took him about 3,4 seconds to figure out how to adjust the settings (I doubt even a number code locked PCA [patient-controlled analgesia] pump would have stopped him, but at least it would have shows some effort in not giving an addict effectively free rein with their opiates... I poked some gentle fun at this in Lunar Landscapes
  • tiny wounds and dressing after an injury or other emergency necessitating major emergency surgery that would invariably mean a big wound

     

Taking a trip with an ITU patient

ITU patients might need to be taken to the operating room, to the radiology suite or even to another hospital. This requires packing up all meds you might need to administer, making sure everything is taped nicely into place (especially the intubation tube – don't want to be reintubating someone in a moving ambulance on the motorway!) and making sure the infusor pumps have enough stuff for the duration of the trip.

You will also need a portable respirator and an oxygen bottle to hook up to it. And, you need something to keep the patient warm (especially in the Scandinavian winter…). And, you need enough manpower to help you out. A driver, a nurse and a doctor are a minimum for transporting a patient on a respirator.

An example of a portable respirator.

 

Are there lots of private rooms available at ITUs?

Not in most places. It's handier for the nurses to be able to keep an eye on each other's patients and help one another out. In general, ITU private rooms are for patients who need to be isolated because of an infection or because they're at risk of getting one. Burn units might have private rooms for the more severe cases to enable climate control.

I've yet to see a fic where they put Sherlock in a regular, several-patients' ITU room. This is fine. I'm sure Mycroft made some calls and got him that private room.

The nurses might well leave him alone in the room with John for a while, but likely not with someone who has no medical training. There would be a nurse in the room with him all the time otherwise. This reality was something I had to get creative to circumvent in The Breaking Wheel.



Would John be allowed to weigh in on the medical decision-making of a friend or family member at the ITU?

Not outside the capacity of a trusted friend or family member. Doctors in the UK are not allowed to treat or prescribe medications to people close to them. This is a rule I have, however, bent in my writing. Harmless Things is a good example of a situation in which John's role easily extends beyond the norm. Early in The Breaking Wheel, John argues with an A&E doctor on who should deliver Sherlock some devastating news.