This is the third part of a series examining the medical aspects of ABC’s new medical drama called The Good Doctor which highlights the struggles of autistic surgical resident Shaun Murphy. You can read Part I and Part II by following the links.
Episode 2 has so many issues it’s taking me two posts just to cover it.
The other issue in Episode 2 is the care of a young girl with abdominal pain. Everyone but Dr. Murphy thinks this belly pain is caused by the girl’s parents’ divorce.
Issue #1: Ordering proper medical tests. One of the easiest things I feel like a medical show can get right is ordering the proper tests. Any medical consultant worth their salt should be able to assist the writing staff in this. For this patient, a child suffering abdominal pain, he orders a D-dimer, lactate, and amylase. Together, these tests make little sense. A D-dimer is used to look at blood coagulation. A lactate at how acidic the blood is. A lactate isn’t crazy, but a more applicable test for this girl would be what’s called a BMP or CMP— both of which are metabolic panels that look at the function of several organs in the abdomen. An amylase is okay as well— but drawn with other tests that make more sense. How about just a plain x-ray of her abdomen while we’re at it?
Issue #2: Going to a patient’s house. Despite the inappropriately ordered, fairly normal lab tests, the results bother Dr. Murphy so much that he goes to the patient’s house and insists on examining her. I cannot emphasize how much this would be frowned upon and I have personally never seen this happen. How would this be handled? First, simply a phone call to the family and request they come back to the hospital for further studies. If the situation is deemed serious enough, and the family cannot be reached by phone, involving law enforcement to help would likely be the next step.
Issue #3: Not calling an ambulance. When the girl is checked on, she is unresponsive and has vomited in her bed. Instead of calling an ambulance, Dr. Murphy insists that they take her by car. In an urban setting (in absence of a mass casualty situation), this is highly irresponsible. EMS response is generally very good and medical care can be started more quickly than driving a patient to the hospital. The episode proves my point when the girl becomes clinically more sick on the drive to the hospital and Dr. Murphy starts CPR. If EMS had been called to the house, this could have been prevented.
Issue #4: When to start CPR? In pediatrics, generally CPR is not started until the heart rate is under 60 beats per minutes. In this case, Dr. Murphy starts CPR for a weak, thready pulse. Looking up American Heart Association guidelines for pediatric CPR would be an easy way to figure out when CPR would be indicated.
Issue #5: Inaccurate medical portrayal of shock. When the 10 y/o girl arrives to the hospital, Dr. Murphy states, “Patient is a ten-year-old female with hypovolemic shock and bradycardia.” Hypovolemic shock is shock related to fluid losses, but seemingly this patient has vomited one time. Really not enough to set in shock in the older child. Also, the body’s response to hypovolemia is to increase the heart rate. The patient should be tachycardic. A pediatric patient can become bradycardic, or have very slow heart rate, in relation to shock, but it is a very late sign and I don’t think the medical history given on this girl is enough to warrant a code.
Issue #6: A surgical resident taking a patient to the OR. Keep in mind, Dr. Murphy is like on day #2 of the first year of his surgical rotation, yet he orders an OR, takes the patient to surgery, and is only interrupted by his attending when he’s about to make his first incision. Just no, no, no.
I think overall The Good Doctor has good intentions in looking at how people with special needs can operate in certain professions. However, don’t look at the first two episodes as any representation of good and accurate medical care.
There is always a way to maintain tension and conflict while still being medically accurate.
Redwood's Medical Edge 
I’m with you, but I felt like they wrote Shaun going to the house to show that he does inappropriate things AND they backed it up with backstory. That doesn’t mean it’s the best choice, but that our protagonist made the choice to do it. I was so freaking out on his behalf when he was at the door, like, you did NOT just do that!!!! oi!
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Okay, Grace. I can see your point on this issue. But, he should be reprimanded. When I give lectures on this topic for writers, I always say a medical character can do bad things, improper things, they just need to face the consequences for their actions. This always ramps up the tension and conflict which is always the goal for fiction.
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I wondered about the show and now that I see your comments, I think we should send your name in as the new medical consultant. Love your blog!
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I keep putting it out there, but they don’t call . . . they don’t write . . . :(.
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A young girl presents with abdominal pain? Order a CBC! They’re cheap! Elevated white count? Check the appendix! It should be the first thing you check in this age range (well… second, after “when was your last poo”).
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Good points. Although, all belly pain does not mean appendicitis either. I am, however, one who believes in screening diagnostic x-rays for abdominal pain. Nothing like a CT scan that just show constipation.
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Absolutely. I’ve only ever worked in rural hospitals, so CT isn’t even an option. Appendicitis usually goes examination, bloodwork, ultrasound, and then OR.
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This succession of studies is true except ultrasound doesn’t always show the appendix (I know, surprising.) So, if the US is not conclusive the patient would likely have a CT scan at that point to determine appendicitis.
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I am kinda surprised you did not point out severe mistakes done with CPR.
My healthcare system guidelines clearly state:
1. Never transport a patient that is not stable
2. CPR is never done on the run. You stop, you call for help (EMT, as you pointed out. The ambulance) and start CPR.
3. Once the ambulance arrives, defibrillator is applied.
4. Of course there are countries with paramedics, who are trained to perform things such as intubations. In countries like mine, the hospital will send you a complementary vehicle, boarded by a medical doctor – anaesthetist who will make sure the patient is sufficiently stable for transport. As an ambulance BLSD rescuer, I cannot perform internal procedures (such as getting a venous access or intubate a patient), yet I can keep him alive until the anaesthetist arrives.
5. Eventually, we have a machinery called LUKAS that can perform CPR on the run, so that you can eventually transport the patient while CPR is being done (even on the chopper).
Cannot wait to read your comments on episode for, in which they do carry an ex-planted liver in unconventional ways!
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Hi Jacob,
Now I’m curious to know what country you are working EMS in. I did watch the episode where they were carrying the liver to be transplanted. It is sooo unrealistic I have chosen not to highlight it on my blog. I mean– there’s no way that organ could be transplanted after what they put it through. After the dissection on top of the cop car in a non-sterile environment in the middle of the blazing heat and hot car hood– there’s not enough room to blog about how wrong that is.
We have tried those automatic CPR machines here in the US, but for some reason they don’t seem to be sticking. Not sure why. I haven’t really seen them used by EMS here.
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I’m about done with the show, with the introduction of this a**hole chief of surgery, I just can’t stomach the arrogance of this piece of s**t. Take a somewhat interesting story and introduce a disgusting antagonist and ruin the show.
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Agreed. I stopped watching it long ago. I may go back and try to watch simply for fodder for the blog, but I completely understand your frustration.
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