New Amsterdam and The Law: Real or Not Real?

In Episode Two of the new NBC show New Amsterdam, there are some pretty amazing claims about two specific laws. Keep in mind, I’m not a lawyer, and this blog is for fiction writers so you might be interested in doing your own research, but these are my thoughts on these “two laws”.

Law #1: In one scene, a man is standing outside his room complaining that he must choose between his wife’s care and a car— eluding to how expensive the medical care will be and that the hospital won’t tell him how much it is. Dr. Goodwin says in passing, “Congress actually made it illegal for hospitals to disclose prices to you.”

Having worked in health care for twenty-five years, I understand how frustrating this can be and there definitely needs to be reform in this area. However, let me give some insight into why it is hard for hospitals to give you an exact price up front. Simply, humans are not machines and often do not medically act the same in every situation.

Let’s say your child comes in for stitches and we tell you it costs “X” amount. This assumes your child only needs a topical numbing agent for the procedure. However, your child is not on board with the medical plan and won’t hold still for his stiches so a decision is made to give them some sedation— and the topical medication isn’t enough to numb the site so we then have to inject a medication. Since the child received sedation, now there’s increased monitoring time to make sure the child is okay to be discharged home. Things like this happen every day in healthcare.

The problem is when you quote someone a price, they want to (rightly so) hold you to it. When you can’t, then it creates dissatisfaction for both the patient/family and the hospital.

Despite this, I could not find any such law that congress has passed that prohibits a hospital from disclosing prices. I think the reluctance is on the side of the hospital for the reasons I mentioned above. In fact, there seems to be movement legislative wise, in the other direction for more transparency. You can read the American Hospital Associations thoughts on it here.

Law #2: A young boy is brought in for psychiatric treatment and the psychologist on staff believes he’s being overmedicated and wants to wean him off all his meds. Quick note on that— not sure why a neurologist would be involved in this process. A psychiatrist, yes.

There’s a statement made regarding the Prohibition of Mandatory Medication Amendment of 2004. As from the link, this law does exist. Put very simply, a school cannot force a child to take medication to receive educational services. However, in the show, it’s stated that the school can force a child to take meds for educations purposes if the mother has signed an IEP otherwise known as an individualized education plan.

I could not find any source to support this statement. This blog post written by a mom who seems familiar with this issue would be a good one to read. Do I believe that schools try to “strongly suggest” that kids are medicated. Yes, I do. However, I don’t think it’s supported by law.

New Amsterdam: Prioritizing Epinephrine Over Oxygen

New Amsterdam is a new medical drama on NBC this year. You can see my first post about it here. Today, I wanted to review a medical scenario with you and the problems with they way it’s presented.

As I discuss the scenario remember that all medical providers are taught this from the very moment they step into medicine: A, B, C— Airway, Breathing, Circulation.

Here’s the setup: A man travels from Liberia where he begins to exhibit signs of Ebola. They place him in isolation (a good move). A big lecture is given by Dr. Max Goodwin, the new medical director, that no one is EVER to enter the isolation room without the proper PPE (Personal Protective Equipment). From there, it gets a little bit strange.

The first issue is that it’s stated that the isolation room is “stocked with every available medication should the patient need to self medicate.” A few problems. A sick and deteriorating patient is going to have the wherewithal to find a drug and give it to himself? This is later proven to be a bad idea when the patient can’t even reach for an easily accessible oxygen mask without falling out of bad.

Also, everything in the isolation room is going to get thrown out and likely charged to the patient so for a medical director who is so concerned about minimizing costs for the patient . . . well, you can see where I’m going with this.

The patient begins to cough up blood, bleeding profusely from his mouth, and has difficulty breathing. As the doctor is getting into her PPE, she instructs him to give himself oxygen which he is unable to do and then falls out of bad. Without getting into full PPE, she enters the room to help.

I actually like this aspect of the show. As I’ve said all along, medical people can make bad choices, as long as the writer shows repercussions for them which they do in the show.

The doctor immediately begins to work to aid his breathing. This is the right choice. She believes the airway is too obstructed so she immediately moves to a needle cricothyrotomy. This is generally done as a rescue measure when other attempts to secure an airway have failed— it is not the first choice.

However, as the doctor inside the isolation room is generally doing most of the right things, Dr. Goodwin (the new medical director) is telling her to give the patient an IV dose of Epinephrine before she gives him oxygen. He tells her to prioritize the epinephrine over the oxygen. At the screen shot to the right, what’s obvious is that the blood pressure (82/40) is low and that the patient’s oxygen levels are REALLY low at 64% (normal is generally considered above 90%).

There really isn’t an indication for epi IV (as in a code dose) in this scenario. The first two reasonable thoughts for this patient’s low blood pressure are sepsis (low blood pressure caused by overwhelming infection) and blood loss from the obvious hemorrhage. Epi can be given in this situation (for low blood pressure related to sepsis) as a continuous drip, but not as a push medication.

Most importantly in this situation, epi would not be prioritized over the patient’s alarmingly low oxygen levels.

New Amsterdam: A Problem with Repetition

For you, my faithful reader, I took in the latest foray into the medical drama by watching New Amsterdam. I was hesitant because of being burned recently by The Good Doctor and The Resident. I know, some of you are loving those two shows, but let’s try to be somewhat medically accurate if you’re going to write a medical drama.

Anyway, I decided to give New Amsterdam a try. It stars Ryan Eggold as bright and shiny new medical director, Max Goodwin, at the healm of a safety net hospital called New Amsterdam. He’s a flawed character, which I liked, and he’s in charge of a staff where they’ve had a new medical director every year for the last five years.

Of course, his moral center is to upend the system for the benefit of patients and not necessarily the gain of money. This is in itself strange since they make it a point to say this is a public service hospital— which still needs to worry about money— but the feeling is different than working at a for profit hospital.

To carry through his moral center, he needs to make big changes fast. I’ll step through some of what I found problematic with the first episode, but I was intrigued enough to keep watching so I’ll keep you posted.

Problem One: One of his first acts as medical director is to fire the entire cardiothoracic surgical team— like every. single. one. Put aside that generally there are a lot of hoops to go through when firing anyone, particularly a doctor, this action puts the hospital at risk of not being able to serve the people he wants so desperately to save. Level I trauma centers must meet certain requirements in order to keep their doors open and firing the entire cardiothoracic surgical team is going to put this in significant jeopardy.

Problem Two: Committing a patient to inpatient psychiatric treatment to keep her out of foster care. Again, as with my recent post on the movie Unsane, there are strict laws on how long you can involuntarily commit someone and generally it needs to be reevaluated on a weekly basis. So, though commendable (because she does like the staff where she is and it would keep her safer than where she’s been), it’s just not feasible that any scenario like this would ever pan out.

Problem Three: Saying the same thing, but fancier. Sometimes I wonder who they find to be medical consultants for these shows. There must be someone. Then I wonder who this someone is and what is the nature of their medical background. In two different areas of the show, the doctor is basically saying the same thing.

Here are two examples:

1. “The patient got diazepam and Valium.” Okay, awesome. These are exactly the same medication. So, you gave the same drug twice?

2. This is a set of orders given by an ER physician. “I need a CBC, BMP, Chem 7 and a saline lock.” Sweet! A CBC is a complete blood count, however a BMP (basic metabolic panel) and a Chem 7 are the same test.

Overall, an intriguing show and I’ll give it another try, but I’m also available for medical consulting!

Lifetime Movie Killer Twin: Killing Nice People Needlessly

As with all television networks these days, the Lifetime Channel could use a good medical consultant as well. In a recently aired movie, Killer Twin, not only (Spoiler Alert!) does the main character, Kendra, have an maniacal unknown twin sister trying to end her life . . . the writers aren’t helping her out too much either.

There will be spoilers for this movie in this post so you’ve been warned.

The plot revolves around the heroine, Kendra, whose life is perfect. She was a twin, but the adoption agency didn’t disclose that and she was adopted as a single child, leaving her twin sister to suffer in the foster care system. Now her twin wants her life and wants Kendra dead.

The main attempt to do this is to expose Kendra to poppy seeds, of which she is deathly allergic to, via a conveniently delivered fruit basket— oh, and steal her epi pen so she can’t save herself.

Thankfully, Kendra’s mother is with her and calls 911, but the attempted murder plot lands her in the hospital.

Here are the following problems with this scenario.

Problem One: Twins aren’t necessarily allergic to the same thing. Can they be? Sure, but it would have to be proven out. For instance, if a mother were to tell us in the medical sphere that a patient’s twin sister is allergic to penicillin, but the patient has never had it, we would still give it a try. It’s presumptive in this movie to assume that because evil twin has the allergy, so would the good one.

Problem Two: Unnecessary Hospitalization. It’s actually very rare for a person having an anaphylactic reaction (which is life threatening if untreated) to land in the hospital. Most of the time, they are observed in the ER for several hours and sent home with medications to take over several days. I’ve outlined the treatment for anaphylaxis in this post. Also, the heroine, who is six weeks pregnant, is told that the medical team admitted her overnight because “a lack of oxygen and toxins could hurt the baby.”

First, let me mop up the blood that just shot forth out of my eyes.

Poppy seeds are not a toxin. They’re a food item. There’s no evidence given in the movie that the character stopped breathing and therefore suffered a loss of oxygen. If you claim this— let’s at least put the character on a monitor to watch her oxygen levels. Lastly, you can’t monitor a baby at this point in any way and isn’t a justification for staying in the hospital.

Problem Three: Killing people with the wrong IV solution. The picture on the right shows the IV solution they were “running” on her (explained in the next section) which is sterile water. Flat out, this will kill people for reasons I won’t go into here. It is never used as an IV solution.

Problem Four: The IV tubing goes into the pump. Honestly, if you’re going to park a piece of medical equipment at the beside, and have a nurse check on it, then know how to use it. As noted in the photo, the IV tubing is not loaded into the IV pump.

Sadly, sweet Kendra doesn’t need her evil twin to kill her, the writers are doing their best on their own with this medical set up.

 

Modern Family: S10/E7 Disclosing Pregnancy Results

This blog post does contain spoilers for episode seven/season ten of Modern Family— you’ve been warned!

On a recent episode of the wildly popular ABC series Modern Family  (which I personally thoroughly enjoy) it was disclosed that Haley Dunphy is pregnant. However, the way her pregnancy was disclosed was a violation of patient privacy.

In the episode, Haley and her boyfriend, Dylan, are playing bumper cars when he playfully rear ends her while she’s applying lipstick (yes, in the bumper car). The end of the lipstick gets shoved up her nose and breaks off leading to a trip to the ER.

Evidently, Haley was given anesthesia to remove the piece of lipstick from her nose. They also x-rayed the nose (at some point) because they tell her it’s not broken. There’s some witty banter about how the injury happened and that she and Dylan want to remain childlike as long as possible which is when the doctor says, “Oh, we did a pregnancy test prior to your anesthesia and you’re pregnant.” This was done via a blood test.

Problem One: There’s really no reason to give anesthesia in this case. We remove foreign objects from pediatric noses all the time and never give anesthesia. Anesthesia is reserved for the OR. Sometimes, a patient might need a little something to chill them out for a procedure, for which we would use nasal Versed or Fentanyl. You don’t need to start an IV and recovery is not too long.

Problem Two: Not even sure why they needed to do an x-ray for a broken off end of lipstick in the nose. I don’t think the mechanism of injury warrants even thinking the nose is broken. Lipstick is soft after all.

Problem Three: A blood test used to determine pregnancy. This is rarely done and would be used more specific to determining pregnancy where problems in early pregnancy might be the concern— such as ectopic pregnancy or early pregnancy miscarriage. In this case, a urine test would suffice.

Problem Four: These days, disclosing pregnancy results must be done very carefully. As healthcare professionals, we don’t know who the male is at the bedside and if the patients wants that male to know about the pregnancy or not. The doctor should have asked Dylan to step out of the room as she disclosed the results to Haley. Then it’s Haley’s decision about whether or not to tell her boyfriend. The same is true if we discover a teen is pregnant in the ER who might be there with her parents. The parents are asked to step out and we’ll tell the teen. It’s up to her whether or not to disclose the results to her parents. We as healthcare professionals will encourage her to do so, but it is ultimately her decision.

I think the best way to have handled this situation would have been to perform the pregnancy test prior to her getting an x-ray of her nose, but even this would be a little outside the norm because shielding her abdomen would have been easy in this scenario.

Dr. Strange Should Know Better

If you haven’t seen the movie Dr. Strange, you have been warned that this blog post will contain spoilers to the movie.

Dr. Strange, released in 2016 as part of the Marvel Universe, features a stereotypical, obnoxious, arrogant, and rich neurosurgeon. He is greatly skilled, but is known to turn down patients in order to keep his perfect surgical record. Unfortunately for the character, he is in a terrible car accident and both his hands sustain multiple fractures that cause permanent nerve damage and therefore lead to the end of his promising career.

Dr. Strange is like many patients when the medical establishment can’t offer complete healing. He begins to investigate alternative/investigative medicine for treatments. He hears from a physical therapist that a patient with a complete spinal fracture is up and walking around. Dr. Strange responds to this by saying, “Show me his file.”

I’ve said all along in this blog that medical people in films, television, and novels can do bad things. Your job as the writer is to let the reader know that you know that the character is misbehaving in his role. This allows the reader to know you’ve done your research and they can trust you as an author.

Dr. Strange asking for this patient’s chart if flat out a HIPAA violation. He never cared for the patient and he has no right to know what’s in his medical record. There are consequences for HIPAA violations and having the character suffer these is a great way to add tension and conflict to the story.

A second medical violation in the movie is the treatment of Dr. Strange’s chest wound. He suffers a blade wound to the chest and transports himself back to his old hospital to be treated by a colleague. There are a few problems with this scene.

Problem #1: That there is a sterile operating room in the ER. No, this isn’t standard. Can sterile procedures be done in the ER? Yes, but not a sterile operation as in the OR.

Problem #2: Wrong ECG rhythm. Dr. Strange has diagnosed himself with a pericardial tamponade. A cardiac tamponade is where fluid is collecting in the sack around the heart thereby impinging on the heart’s ability to pump blood.

The rescue procedure for this is a pericardiocentisis— or removal of the fluid from around the heart. His love interest confirms the diagnosis by percussing his chest. This is probably the least reliable way of diagnosing this problem. Any well equipped ER should have some sort of bedside ultrasound to aid in the diagnosis. The ECG monitor first shows a rhythm of bradycardia— the heart beating too slowly. This again is one of the least likely rhythms related to this condition.

Problem #3: Wrong placement of the needle. In the movie, the doctor is shown placing the need straight into the chest. It should be at an angle pointed to the left shoulder which this nifty video on You Tube shows.

Problem #4: Shocking asystole: I’ve blogged a lot on this. You cannot shock asystole. It won’t improve the outcome for the patient and is contraindicated. First treatment is high quality CPR and a dose of epinephrine or adrenaline. Also, this is not the correct paddle placement for defibrillation. It should be just to the right of the patient’s sternum and over the apex of the heart or more to the left side. They also cannot be placed over clothing.

Problem #5: OR is next. Most likely a patient like this with penetrating trauma to the chest would likely go to the OR, or at least some follow-up radiology studies. Not just stitched up and sent on his way.

Something Strange about Dr. Strange

Most love a good operating room scene where a brilliant mind and steady hand save the day. Dr. Strange fulfills this role in his self-titled movie and was most enjoyable to watch.

However, there is one scene that concerned me.

See anything strange besides the man who carries the name?

The two main characters are creating a burr hole in the skull to be able to retrieve the bullet lodge near the medulla. The are in full sterile attire except for their masks.

Several years ago, I was called to the OR to assist with the removal of a brain tumor guided with ultrasound. No one in that room went without a mask covering their mouth and noise. In fact, I was not even allowed to enter the suite without a mask in place.

All of the surgeons, nurses and surgical assistants surrounding the table also wore face shield to protect their eyes from any splatter of the patient’s biological fluids.

So you can imagine my disdain when watching the movie, Dr. Strange, and discovering two surgeons hovering over a patient’s head, creating burr holes in his skull without masks. Upon further research, the wearing of masks in the OR has caused some controversy.

According to Lisa Maragakis, Senior Director of Epidemiology and Infection Control at John Hopkins Health System, some studies have shown the absence of a mask in the OR “have virtually no bearing on the patient outcomes when surgeries are performed by healthy doctors in sanitary operating rooms.” (Maragakis, 2016) In some European hospitals, surgeons are no longer required to wear masks.

However, she also discusses what happens when a surgeon sneezes. Personally if it were my open brain, I’d not want my surgeon’s droplets nestling into my head wound.

Here in the US, most hospital and operating room protocols still require our surgeons to don the traditional surgical mask and encourage facial shields.

Perhaps, one day that will change, but right now, I’m glad wearing surgical masks are not strange.

References:

Sugarman, J. (2016). What Do Surgical Masks Really Protect Against? Retrieved May 28, 2018.
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Shannon Moore Redmon writes romantic suspense stories, to entertain and share the gospel truth of Jesus Christ. Her stories dive into the healthcare environment where Shannon holds over twenty years of experience as a Registered Diagnostic Medical Sonographer. Her extensive work experience includes Radiology, Obstetrics/Gynecology and Vascular Surgery.

As the former Education Manager for GE Healthcare, she developed her medical professional network across the country. Today, Shannon teaches ultrasound at Asheville-Buncombe Technical Community College and utilizes many resources to provide accurate healthcare research for authors requesting her services.

She is a member of the ACFW and Blue Ridge Mountain Writer’s Group. Shannon is represented by Tamela Hancock Murray of the Steve Laube Agency. She lives and drinks too much coffee in North Carolina with her husband, two boys and her white foo-foo dog, Sophie.