Details do matter to readers

Yesterday, I received the following email from a reader:

I am currently reading “The Surgeon”, and I wanted to question a few technical points.While I am only a nurse practitioner, I worked in the ICU for almost 15yrs. While it seems silly and ridiculous to email over such small details that the average reader would have no clue as to their accuracy, I wanted to clarify a few points (again, as silly and ridiculous as they may be).

O positive is the “universal donor”, not O neg. The rH factor difference would cause a transfusion reaction.

While DIC a common possibility in the post-op patient who is bleeding out, I have never seen it in a trauma patient in less than 6 hours post injury. Physiologically, it takes hours for the coags to become so out of whack that DIC begins.

In addition, the use of Heparin in a DIC patient is very risky and is not done (at least in my clinical experience), unless there is a confirmation via the lab results that all other differential diagnoses are ruled out.

Finally, LR is not normally referred as Ringer’s lactate. In an ER/ICU it is referred to as Lactated Ringer’s – an isotonic fluid (NS is the same, but in TNCC certification, LR is preferred)

While I am not a physician, these details are important ro a reader who knows trauma and medicine. If I am incorrect, please feel free to let me know. No one kn\ows everything,

Oh, by the way, in future books, if you are talking about a nurse, instead of saying “nurse- do this or that” give him or her a name and refer to them by that at tag the nurse title after the name. Again, a silly minute detail.

These comments relate to an early scene in THE SURGEON, in which a trauma patient comes into the E.R. In the frantic moments that follow, my heroine, Dr. Catherine Cordell, makes a number of life-and-death decisions, and manages to save the man’s life. Although that scene is only eight pages long, this reader found a number of details that troubled her, and she took the time to write me about mistakes that she felt I had made. Did that email trouble me or irritate me?

Not at all.

Although it turned out she was mistaken about several points (O-negative is, in fact, the universal donor blood type, and “Ringer’s lactate” is what many doctors actually say when they want what’s formally known as “lactated Ringer’s”. Also, the patient had cancer, which would explain the rapid onset of DIC, aside from the trauma) I did not mind responding to her email, because her criticisms were polite and friendly — even if they were not correct.

Other readers have not been so kind. One reader sent me an email lambasting me because I’d referred to Aphrodite as the goddess of love. “Don’t you know that Venus is the goddess of love?” she wrote, amazed that I could be so misinformed. “Everyone knows that!” She included links to Botticelli’s painting of Venus rising from the sea on a clamshell, to support her stance that I was an ignoramus. I took a few deep breaths, then responded with a link to Wikipedia about the parallel pantheons of Roman and Greek gods, explaining that Venus and Aphrodite were names for the same goddess of love. (I love Wikipedia.)

I never heard back from her. Which is par for the course. The readers who build up the biggest heads of steam about my being an idiot are often not amenable to being corrected.

Still, I welcome such emails because I’ve learned so much from my readers. I’ve learned that you are never a “former” Marine. (I will never make that mistake again!) I’ve learned that Ford did not manufacture automobiles during WWII. I’ve learned that the “scleral hemorrhages” I described in Gravity should have been called “conjunctival hemorrhages” instead. I’ve learned that my understanding of the term “immaculate conception” is incorrect, and is more accurately called “virgin birth”. I’ve learned so much from my readers, and I always welcome enlightenment, if it’s offered in a friendly and non-threatening way. And when my readers are incorrect, I hope that they’re happy to be enlightened in return.

Here’s how I answered that email from the nurse:

I’m always glad to hear from someone in the field! And I deeply respect anyone who’s been an ICU nurse. Wanted to go through some of the points you bring up.

Re: universal donor blood type. According to this website, O neg is considered the “universal donor type.”

“Type O-negative blood does not have any antigens. It is called the “universal donor” type because it is compatible with any blood type. Type AB-positive blood is called the “universal recipient” type because a person who has it can receive blood of any type. Although “universal donor” and “universal recipient” types may be used to classify blood in an emergency, blood type tests are always done to prevent transfusion reactions.”

http://www.webmd.com/a-to-z-guides/blood-type-test

Re: LR versus Ringer’s Lactate. Back in the dark ages, when I was still in practice, in the ER we’d say “Ringer’s Lactate” because it was quicker and easier to say than the five-syllable “Lactated ringer’s”. (Say it quick a few times– it’s a mouthful!) Not technically correct, perhaps, but common shorthand in a tense situation.

As for using the actual names of nurses in the stories, it’s really a matter of what works in a novel. In a quick-paced ER scene, it really slows the action down to have to introduce everyone in the room by name “Tiffany! Jennifer! Amy!”. The more names I add to a scene, the more confused a reader is likely to get by all these people. So unless the character becomes important to the plot, I tend not to name walk-on characters, but call them by their positions (Ward clerk, X-ray tech, patrolman) rather than give them each a name. I think you’ll notice that in crime scenes, I seldom name the individual crime-scene techs, either. Unless they have more than a walk-on role.

And yes, giving heparin in a situation of unconfirmed DIC is a dangerous thing to do. But novelists do get dramatic license to make a scene more exciting!

I don’t know if she welcomed the response. But I always appreciate having my mistakes corrected, so I hope she did too.

23 replies
  1. GerritsenFever10
    GerritsenFever10 says:

    I’m surprised that NP said anything. I wonder if she realized that you are a doctor and have been through more training than she has? Hmm…people tend to annoy me. You did better than I would’ve had I been in your shoes. As if you don’t know the detailed ins and outs of all of what you were describing! That irks me, sorry. I’m glad you kept a cool head about it, though. I would never have questioned anything about that ER scene because I knew you knew what you were talking about especially since you’ve had actual MD training. Anyway, that’s my soapbox for the day.

  2. therese
    therese says:

    This nurse practitioner’s tone and queries are polite and legitimate. I’m glad you felt that as well, and responded in kind. (There is nothing “only” about a nurse practitioner!)

    My brother worked ER for years until he became a profusionist (sp?) [runs the heart-lung machine during open heart surgeries] and another friend is an ER nurse in America, but is currently living in London. From these two personal connections I know there are a lot of differences in terms and standard practice depending on hospital and even part of the country.

    It’s highly possible she’s perceived certain terms and practices but never questioned the nurses and doctors for clarification.

    However, little as the rest of the terms meant to me, I was surprised at her statement that O pos is the universal donor, since I hear it is O neg, all the time, especially during blood drives. The reason being, myself and all 4 of our daughters are O neg, so create a stir of appreciation when we roll up our sleeves. 🙂
    We also get calls, letting us know where and when the next blood drive will be. It’s a common joke in our house, “They Vaunt my blood!”

  3. l.c.mccabe
    l.c.mccabe says:

    Tess,

    Blood banking.

    A subject I can sink my teeth into. 😉

    Yes, O negative is the “universal donor” blood type, but *only* if it is packed red blood cells. While whole blood is hardly ever used anymore, it is still important to specify the blood product along with the ABO and Rh type.

    Watching old M*A*S*H re-runs shows hanging whole blood in bottles, so during that time it was imperative that type specific blood was given. Current transfusion practice allows for using type compatible O Neg packed red cells in an emergency, but it would not work in historical settings.

    The Web MD webpage you cited is mostly correct, but there are a few things that made me wince. I think that is because it was likely written by a physician (or another health professional) but not by a blood banker.

    I looked to see if the American Association of Blood Banks had anything better on their site and came across something I think you’ll love. It is an historical timeline of blood transfusions. The first entry is in 1628!

    http://www.aabb.org/Content/About_Blood/Highlights_of_Transfusion_Medicine_History/highlights.htm

    or this:

    http://tinyurl.com/qjlwuw

    As for the Web MD,

    They wrote:
    “Type O-negative blood does not have any antigens.”

    Me: It should have said that type O-negative packed red blood cells lack ABO antigens which can cause transfusion reactions and lacks (D) or the Rh positive antigen which can cause antibody production later in Rh negative individuals.

    I know it is not as concise, but it is closer to accuracy.

    The ABO system is the most important of all the blood groups, because if ABO incompatible blood is given it can be lethal.

    Web MD was also a bit simplistic about discussing the Rh system. It is far more complicated.

    The Rh system is made up of several antigens, C,c,D,d,E,e (and then obscure ones.) The most important antigen is D. If you have big D, then you are Rh positive. If you lack D, then you are Rh negative. If you are Rh negative and you are transfused with Rh positive blood you *will* develop anti-D.

    It’s a potent antibody and can cross the placenta causing miscarriages, spontaneous abortions, stillbirths or Hemolytic Disease of the Newborn, (HDN.)

    You can also develop anti-D if your body is exposed to Rh positive blood during pregnancies or childbirth. With the advent of Rhogam, Rh negative women are given shots during and after pregnancy (or after miscarriages, abortions, amniocentesis, etc.) to prevent their immune system from developing that nasty antibody which historically caused so many fetal deaths.

    (BTW I think that may have been what caused Catherine of Aragon and Anne Boleyn to have one healthy child and then a series of miscarriages.)

    The WebMD site also mentions “Minor antigens (other than A, B, and Rh) that occur on red blood cells can sometimes also cause problems and so are also checked for a match before giving a blood transfusion.”

    Yay! I am glad they mentioned this, because it is important. Those antibodies for the lesser blood groupings are why blood bankers have to perform antibody screens to discover if the patient has antibodies to such groups as Kidd, Kell, Duffy, and the MNS system (among others.) If a patient has an antibody to one of those blood groups it can cause what is known as a delayed transfusion reaction.

    Days after the transfusion the patient will start to suffer. Antibodies will start coating the transfused cells and be destroyed at a rapid rate causing the patient’s hemoglobin to drop. It can also be hard on the liver to process all those lysed red cells.

    Antibodies are created when an immune system says “hey I don’t like this foreign body” and mounts an immune response.

    In the blood bank, antibody screens are done to discover if any unexpected antibodies are present, to identify them and to find blood for transfusion that lacks the offending antigen.

    That’s the risk in giving uncrossmatched blood. If the lab hasn’t had enough time to run all the tests, there is the possibility the patient may have an unexpected antibody. But in emergencies, the worry about whether or not the patient will bleed to death if not transfused outweighs the unlikely event of them developing a delayed transfusion reaction days later.

    If there is an emergency release of blood, the lab will continue the testing to determine the compatibility of the units signed out.

    Plus, as soon as the blood bank identifies the ABO and Rh of the patient, they will switch lickety split to giving out ABO and Rh specific units, and save the O Neg packed red blood cells for our O neg patients.

    Here is some trivia, from the AABB FAQ section:

    http://www.aabb.org/Content/About_Blood/FAQ/

    What is the most common blood type?
    The approximate distribution of blood types in the U.S. population is as follows. Distribution may be different for specific racial and ethnic groups:

    O Rh-positive — 38 percent
    O Rh-negative — 7 percent
    A Rh-positive — 34 percent
    A Rh-negative — 6 percent
    B Rh-positive — 9 percent
    B Rh-negative — 2 percent
    AB Rh-positive — 3 percent
    AB Rh-negative — 1 percent

    From your friendly neighborhood lab ratt,

    Linda

  4. techiebabe
    techiebabe says:

    I too wondered about blood types when I read The Surgeon – the reason being that the blood service are always writing to me, telling me (as an O+ donor) how valuable my blood is. But they went on to say it can go to 84% of people – anyone who is rhesus positive. Which told me that O neg must be ok for everyone.

    However, I wouldn’t presume to correct an author. I used to hang out on the forum of another very popular author I enjoy, and then one day I found a correction needed in a book (a typo). It was the first week that the book had been out in hardback so I mentioned it in the hope that it might be possible to correct for later editions – while also saying how much I enjoyed the book, of course. I got flamed by forum members for saying something “negative”, and the author basically said she didn’t care about the typo, but I could tell her publishers if I really wanted to. So that put me off bothering, or even daring, again! It also meant I was amazed when I got my first reply from you Tess, and it was friendly too! ;-D

    — Flash Bristow

  5. Norris Marshall
    Norris Marshall says:

    I am shocked, SHOCKED that they may have been innaccuracies in “The Surgeon”. I will immediately demand that I regurn my copy to amazon.com for a full refund (and compensation for the time taken to read the novel). Additionally, I will be going over “The Bone Garden” with a fine toothed comb to ferret out any further egregious errors.

    Ms Gerritsen, you showed grace and courtesy to your reader when responding to her letter. I’ve had my fun with a modest bit of Casablanca-esque humor in the first paragraph; you remain not only a favorite author, but a person for whom I have no small amount of respect and admiration.

    Norris

  6. Norris Marshall
    Norris Marshall says:

    (“regurn” is how we deceased book characers spell “return” by the way; because I do NOT make types!

  7. Jude Hardin
    Jude Hardin says:

    Tess,

    I read a book recently where one character hooked up some sort of field transfuser contraption and pumped some of his blood into another (injured) character. Can you imagine? If the possibly-mismatched blood type didn’t kill the guy, then clots to the lungs or brain probably would. Don’t try this at home! I didn’t call the author on it, because, really, once something is published, what’s the point? I have to say, though, it took me completely out of the story, and it really wasn’t even necessary. It would have been much more believable if the character had simply survived without the transfusion.

    As an MD, do medical inaccuracies in novels sometimes just make you cringe?

  8. Liz Wolfe
    Liz Wolfe says:

    I once referred to my husband as an “ex-Marine” (to a Navy guy). I won’t make that mistake again, either…LOL.
    I’ve never had a reader question an inaccuracy in one of my books, but when it happens, I hope I respond as graciously as you did.

  9. Tess
    Tess says:

    thanks for all the comments!

    Jude, I too get pulled out of a novel if I encounter a medical detail that I know to be directly contradictory to science. For instance, I read a novel where it was clear that the author didn’t understand the difference between viruses and bacteria. I’m fine reading fantasies about wizards and magic, because you understand going in that it’s fantasy. But when a story is supposed to be fact-based, the details do matter. That said, I myself make mistakes all the time, so I’m pretty forgiving of authors who make goofs.

  10. Abe
    Abe says:

    Tess,

    This just shows the amount of style and class you have. You take critcism well whether it be good or bad. I guess you call ’em as you see ’em. Way to go!
    Abe
    BTW, not to sound ignorant, but what is DIC?

  11. annaaleta
    annaaleta says:

    That was a very polite exchange, Tess! While I myself had once had a clinical experience (and here in the Philippines, doctors say D5LR to nurses and not Ringer’s Lactate :), I wasn’t completely bothered by the technical details. Perhaps it was the drama of the scene that took over me.

  12. Jude Hardin
    Jude Hardin says:

    Annaaleta:

    D5LR (5% dextrose in Lactated Ringer’s) is a different solution than regular Lactated Ringer’s. It’s hypertonic, whereas regular LR is isotonic, and the two aren’t at all interchangeable. So, don’t make THAT mistake in your next novel. 🙂

    Unless your POV character is a doctor or a nurse, and unless technical details are inherently important to the story, I think it’s okay to fudge and just say something like the doctor ordered IV fluids…

    Better to leave details out than to get them wrong, IMO.

  13. Tess
    Tess says:

    To follow up on RL vs. LR, (in case anyone’s interested!) I’ve found a number of articles in published surgical journals that refer to it as RL.

    (e.g., from one article: “Extracellular fluid deficit following operation and its correction with Ringer’s lactate. A reassessment.
    J P Roberts, J D Roberts, C Skinner, G T Shires, 3rd, H Illner, P C Canizaro, and G T Shires

    The changes in extracellular fluid volume (ECV) in two groups of surgical patients, one receiving Ringer’s lactate solution intraoperatively and the other receiving only dextrose and water…”)

    Also, Wikipedia lists both LR and RL as alternative names for the same solution.

    Amazing, isn’t it, how one little seemingly innocuous detail like this can inspire a letter from a reader?

  14. moe.kay
    moe.kay says:

    Tess,

    You were very gracious in the way you responded to this reader. While I applaud a nurse who questions a doctor about things medical, especially in a clinical setting, what I found a little disconcerting was the NP’s failure to do her homework before firing off an email to you.

    Speaking only to the blood type issue, a quick google search of the terms “blood” and “universal donor” provides many hits stating that O negative is the universal donor blood type.

    I suspect that your response will do more than just inform this reader on the specific technical points she questioned in The Surgeon. Hopefully, in the future, she will be more inclined to verify technical things she thought she knew, whether those things are contained in a novel or her patient’s medical chart.

    MoeKay

  15. Ghasem Kiani
    Ghasem Kiani says:

    Having read several of your books, I am convinced that you research the scientific part of your works very thoroughly. In fact, as a pediatrician, I have always learned many things from your books. Here in Iran, we commonly call that solution “Ringer Lactate” (with a Persianized pronunciation, of course).

  16. PackingPadre
    PackingPadre says:

    Tess,

    I’m a bit put off by the doctor worship of some of the commentators. Physicans make mistakes, just like any other human being. And my general internist and I have had some heated discussions over proposed treatment.

    That being said, I don’t comb your books or anyone else’s trying to play gotcha. There are some authors, you’re not one of them, who should read their proofs more carefully to fix typos or misidentifications of characters.

    And I do hold you, Robin Cook, Michael Palmer, etc. to a higher standard on medical facts as all of you are MD’s. It’s the same with a courtroom novel. I hold a lawyer to a higher standard than I would a nonlawyer author.

    Daniel

  17. annaaleta
    annaaleta says:

    Jude Hardin,

    Thanks for correcting me.
    Going through your comment, what I have missed in more than ten years I’ve been out of practice came back in a whoosh. Guess it didn’t stick as I would have expected it to.

    I strongly agree with you that it’s best to leave out the details if one can’t be sure enough. Besides, too much details could so overload the reader with information that the drama of the scene is pushed behind.

    Haven’t written any novel–at least not yet. I write for soap operas.

  18. Tess
    Tess says:

    Ghasem,
    I just have to say wow, so nice to get a comment from an Iranian doctor! (It’s long been my dream to see Iran.)

  19. wendy roberts
    wendy roberts says:

    I went for coffee with a writing friend yesterday and we were discussing this very issue. We’ve been stunned by the number of readers who will take the time to point out inaccuracies without taking the time to do their own research on the subject. That said, I admit I’m certainly not perfect and that’s more or less my reply when I receive comments that do point out errors on my part 🙂

  20. CareyBaldwin
    CareyBaldwin says:

    I think readers must appreciate your personal reply. That is not only gracious but respectful!

    I loved THE SURGEON! And in fact it inspired me to begin my current WIP. I am an aspiring author and physician, and also struggle with “details”. I sent my trauma scenes to a trauma doc and an anesthesiologist for review. They contradicted each other regarding certain medical details. But both were right. There are judgment calls involved and more than one way to skin a cat. Medicine is also an art.

    I applaud you for working so hard to get it right, and for being open to feedback.

    Thanks for the inspiration!

  21. McIntosh
    McIntosh says:

    Tess:
    I am always amazed at the number of people who love to correct others. Do they not realize they are reading a “novel?” Do they not read the dust jacket which explains you were/are a medical doctor and do know what you’re talking about? Not to mention the detailed research you do for each story. Sheeesh! Lighten up and enjoy the ride! I love your books and look forward to the next one. If I want to know which blood type is the “universal donor” I will pick up Grey’s Anatomy.

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