The Good Doctor: Season 1 Episode 4

I wasn’t sure if I would continue to do these posts on the new ABC drama, The Good Doctor. One of the first posts I did got one of the largest responses ever on my FB page. The responses were 50/50 for and against the show. Many people want to champion the series because it highlights someone with autism working in the medical field.

The other half agree that if you’re going to highlight a medical drama— it would be nice to have it be the teeniest bit accurate. I’m not asking for a lot . . . just don’t give patients false hope or have them get such a skewed view of medicine that they trust medical professionals less. We’re already fighting that battle.

My disgruntlement with the show is not the fact that they highlight a character with autism— it is with the medical aspects of the show and how they handle their patients.

That is where my fight is . . . so let’s carry on.

In episode four, the main story highlights a woman who is pregnant with a child who has a large spinal tumor. The woman has already miscarried two children as the result of a clotting disorder she suffers from.

Issue #1: All surgeons cannot do all things. This continues to be a big complaint of mine for the show. One of the general surgery attendings is also a specialist in fetal surgery. I cannot tell you how specialized a field fetal surgery is. There are only a handful of these specialized doctors in the country. A general surgeon is not even, in their right mind, going to attempt something so risky for a notch on their proverbial belt. It would be negligent for them to do so.

Issue #2: OR’s are well lit. In this particular episode, I noticed all the OR scenes are shot in relative darkness. I’m sure this is so it looks uber cool for the viewer and there are times when OR light is dimmed, but we do generally want surgeons to be really able to see what they’re doing. Which is why they get really big lights.

Issue #3: Medical equipment called for— never placed on the patient. During the first surgery to remove the tumor from the child, the mother suffers a heart attack and they place her on a balloon pump that mysteriously never gets put in place. These are obvious pieces of equipment and it is never shown or mentioned again.

Issue #4: Surgery without patient consent. Despite the pretty serious complication of the first surgery, the mother is gung ho to go at it again, despite having had a heart attack. That’s actually believable. Mothers will do anything to save their child. What’s a little surprising is how gung ho the surgeons are. What follows are some pretty mind boggling discussions of who lives and who dies under what circumstances.

The attending surgeon offers a plan to not tell the mother that her surgery will end up being an abortion to save her life. That they’ll essentially lie to her telling her they’re going to take her to the OR for another attempt at saving the infant while really going in to end his life. On a one to ten scale of how unethical a plan that is to even be mentioned is like one hundred. The better person to float out an idea like that? A medical student. A resident. The attending? Those are the people teaching our young doctors— please have them be a representation of some sort of ethical boundary.

To be clear, the surgical game plan can change during an operation, but to go in knowingly deceiving a patient is malpractice.

Issue #5: The baby is just as monitored as the mother during the surgery.  In the scene of the second fetal surgery, the baby is just lying there on the mother’s stomach with no monitoring equipment. The baby is monitored as thoroughly as the mother.

What are your thoughts on The Good Doctor?

The Good Doctor is Bad Medicine Part 3/3

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.

The Good Doctor is Bad Medicine Part 2/3

I’m continuing my evaluation of ABC’s new medical drama The Good Doctor. You can find Part I here. The series follows first year autistic surgical resident, Shaun Murphy, as he navigates his surgical residency.

The second episode sees Shaun begin his duties and he’s been accepted into the program, albeit with some outward disdain from some of the attending surgeons.

In the opening scene of this episode, a middle-age woman has had a CT of her abdomen that shows a large mass.

Issue #1: Morphine dosing. The patient’s initial dose of morphine is 10mg. This is a little on the high side. Generally, we’ll start with lower doses and work our way up. However, they distress the patient with news of her medical diagnosis and so the attending surgeon says to the resident, “Give her as much Morphine as she wants.” So the way we deal with patient distress is by overdosing them on narcotics? I don’t think so.

Issue #2: Reviewing medical tests in front of the patient. Two surgical residents and the attending surgeon pull up the CT results in front of the patient without having reviewed them first and the test shows a very concerning exam. Dr. Murphy diagnosis her with cancer, in front of the patient, based on this scan. This is reason #1 why you know what the patient is dealing with before you go talk with them. Nothing should be hidden from a patient, but also should the information be presented in a compassionate, informative way.

Issue #3: The definitive diagnosis of cancer can only be made by biopsy. Are some radiology studies highly suggestive of malignancy? Yes, absolutely. But always, the cells must be looked at for definitive diagnosis, which means a biopsy.

Issue #4: Supposedly, Shaun Murphy is crazy uber-smart despite his communication difficulties related to his autism, but he seemingly made it out of medical school without an understanding of what “scut work” is. Sure.

Issue #5: Nursing as boss. In one scene, a nurse is placed as Shaun Murphy’s “boss” to keep him from ordering unnecessary medical tests. Put simply, this is not nursing’s responsibly.  It is a nurse’s responsibility to protect patient’s assigned to her from unnecessary medical testing (or at least question the physician about tests that seem out of bounds), but never would a nurse be assigned to follow a resident around all day to keep tabs on him. This is the responsibility of the surgical hierarchy and they need to keep tabs on this resident. Also, this nurse seemingly works every area of the hospital from the ER to the PACU. This is also unrealistic.

Issue #6: Nurses are called by their first name— not “Nurse” and their last name. Again, can we get rid of this stereotype?

Issue #7: Lab delay in pathology results. Lab works very closely when surgeons are waiting for results with a patient on the table. These would be considered “stat” reads and would not be placed in the normal milieu of other lab tests.

Issue #8: Threats of violence are taken very seriously. Shaun’s response to the lab personnel not immediately reading the pathology slides is to verbally threaten to throw a rock through their window. This is completely unacceptable behavior, regardless of the autism diagnosis of the surgical resident, from any member on a hospital staff and would not be treated with a kind response (as in she smiles and concedes to his demands.) A statement made like this would receive disciplinary action.

Issue #9: These amazing medical centers cannot do amazing surgery. In this episode, the surgical team decides they must cut out the kidney in order to get a better look at the tumor. Fine, great. But why not reimplant it once the surgery is over?

There are so many issues with this one episode of The Good Doctor it deserves a Part III.

The Good Doctor is Bad Medicine Part 1/3

The Good Doctor is a medical drama that’s first season just started airing on ABC. Of course, anytime a new medical drama hits the airwaves I get messages from people curious about my opinion.

The drama focuses on first year surgical resident Shaun Murphy who has autism. I’ve watched the first two episodes and though the premise of the drama is mildly intriguing— I don’t find the medical aspects or interactions between the medical staff worthy enough to keep watching. Unless, I keep analyzing episodes for this blog. We’ll see.

Episode 1 features the fight of a hospital administrator to get him accepted into the program. On Murphy’s way to the hospital for seemingly his first day, of course, he saves a life at an airport.

A teen is showered with glass and suffers life-threatening injuries to the neck and chest. An older male, who identifies himself as a doctor, begins to render aid by putting pressure on the wound. The doctor says, “His jugular vein has been cut.”

Issue #1: Placement of direct pressure. Murphy chastises the older doctor for holding direct pressure improperly (for a pediatric patient) and for occluding the patient’s airway because of it. The doctor adjusts and the patient begins to breathe again. Truthfully, there are differences between the adult and pediatric airway, but I’ve never heard of adjusting pressure d/t anatomy. You have to put pressure on what’s bleeding. If that causes problems with the airway, then the patient requires intubation to protect the airway.

Issue #2: Doctors having sex in the call room. Can we please just get rid of this stereotype? Please, just please. There is never as much rampant sex as portrayed on TV in hospitals. In my almost 25 years of nursing, I’ve heard ONE rumor.

Issue #3: Airport Security. I cannot believe in this day and age that, regardless of what someone says, hospital security would allow anyone to grab a knife and run wildly through the airport without being arrested— even if a patient’s life is in danger.

Issue #4: EMS response. Considering this is an airport, the EMS response time is laughingly long.

Issue #5: Chest tube. Of course, Dr. Murphy places a chest tube in the patient as well as makes, MacGyver style, a chest tube drainage system. Once this is done, he triumphantly raises it above the patient and the patient dramatically improves. Just, no. Drainage systems should always be level or below the patient to drain. Never above. Like never. You can check out this nifty nursing video that explains just that.

Issue #6: Direct OR admission from the ambulance. The now stable patient is met by a surgical resident and goes straight from the ambulance to the OR. No, just no. First of all, why does a stable patient need to go to the OR? Secondly, everything first to the ER. The ER attending will make a decision to consult surgery and a plan will be made to take the patient to the OR.

Honestly, there’s more in this episode. Can we talk about the language the doctor uses to get consent? I’ll spare you until next post where I examine episode 2.

 

Author Beware: Inaccurate Ultrasound Scenes Part 2/2

Today, we’re concluding Shannon’s series on how to write medically accurate ultrasound scenes. You can find Part I here. Today, Shannon is covering tips #3-#5.

Welcome back, Shannon!

Tip #3: Sonographers scan in the ultrasound department most of the time.

Most scans are performed in the designated ultrasound department for their exams, unless they are in active labor, in the ICU or for some astronomical reason, cannot leave their room. Even in the emergency department, if the patient can be transported to the department, then they will be.

Portable ultrasounds are performed on serious cases when the physician does not want the patient moved for some pertinent reason.

 For Writers: If your character needs an ultrasound exam, is conscious, can move well, or sit in a wheelchair, send them to the ultrasound department.

Tip #4:  Sonographers like top of the line equipment.

One television scene at a top-rated hospital showed a tiny little ultrasound machine from the 1990’s being used for the exam. Seriously?

Get rid of the outdated equipment. The machines in top-rated healthcare systems are the best of the best, large and full-sized pieces of equipment.

Modern portable systems look like laptops, are smaller, and are taken to the inpatient rooms or ICU.

Some facilities provide their ER and L&D doctors with tiny devices the size of a cell phone to carry in their pocket for quick peeks, not full anatomy exams.

For Writers: When describing the machine look at top of the line equipment with GE, Philips, Samsung or other manufacturers. This will give you a good idea of what is being used in the real medical world.

Tip #5:  Sonographers know where to place the probe.

Make sure the anatomy showing on the screen matches the location of the probe and the anatomy being discussed is displayed.

One television scene I witnessed had the actor place the probe in the middle of the abdomen, but a kidney presented on the screen. Sonographers know the kidneys are located on the sides of the abdomen, not in the top middle.

If you’re listening to the baby’s heart on a second or third trimester baby, then the heart will display on the screen. Not the brain, fingers, and toes.

If investigating the liver, then the probe needs to be placed on the right side of the abdomen. With the spleen, move the probe to the left side.

If it is a first trimester scan, then a vaginal exam will be performed. If the baby is in the second or third trimester, then the probe is placed on top of the abdomen.

For writers:  Research anatomy and physiology on the internet or in books before writing the ultrasound scene. Make sure the location is correct and the disease process is represented accurately. If unsure, then find a nurse, physician or medical professional to ask or connect with Jordyn and me.

When researching a specific topic, perform a google search, but select a credible source. Choose sites that end with .edu, .org, or .gov. Those tend to be most accurate. Sometimes I will use others, but always back it up with a healthcare system education site like Mayo Clinic, Cleveland Clinic, or the government site (ncbi.nlm.nih.gov).

Don’t be like one famous author, whose patient’s venous blood clot, located in the leg, traveled to the brain and caused a stroke. However, in real life, strokes most often come from the carotid arteries and heart. Venous blood clots in the legs kill when they break off and travel to the lungs.

Shannon, thank you so much for this valuable insight. I know I learned a lot.

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Shannon Moore Redmon writes Romance 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.

 

Author Beware: Inaccurate Ultrasound Scenes Part 1/2

Redwood’s Medical Edge is pleased to host Shannon Moore Redmon, an ultrasound sonographer, and she’s offering her insights on how to write ultrasound scenes accurately. I know I’ve learned a few things for sure. Today, we’ll cover tips #1 and #2.

Welcome, Shannon!

Americans love to watch medical television shows, like Grey’s Anatomy, ER, or House. We buy up the latest medical thriller and discover the scientific world of healthcare.

What many fail to recognize are the glaring inaccuracies associated with the ultrasound profession and the exams being performed on the television screen. Such scenes contain incorrect anatomy, probes placed in wrong positions, or actors who need more camera face time and scan patients backwards.

Doesn’t Hollywood consult experts when they use ultrasound to determine an abnormality of a baby or find cancer in a patient’s liver?

As a registered diagnostic medical sonographer for over twenty years and an instructor who teaches others to utilize this amazing modality, here are five tips to make those ultrasound scenes more accurate.

Tip #1:  Sonographers perform the majority of scans.

Whether in a hospital setting, an outpatient center, most OB/Gyn offices, vascular offices, and general imaging facilities, registered sonographers are the ones who perform the majority of ultrasounds on patients . . . not doctors.

In my experience, sonographers scan the patient first and sometimes are the only one who take the images. If a patient is high-risk OB, a sonographer will scan her first, then a maternal fetal medicine doctor will scan after to confirm the diagnosis.

When abdominal or vascular ultrasounds are performed, sonographers scan these patients and the reading physician or surgeon may come into the room to discuss with the patient. More than likely, they will read the images from a digital archiving system located in their office down the hall, then attach a report to the patient’s medical record.

Most episodes on television have a doctor performing the exam. Where have all the sonographers gone? Having lunch together down by the river?

For writers: When writing your ultrasound scenes, let the sonographer take the images and discuss the case with the reading physician. If you want to ratchet up the drama, then let them have a heated discussion over what the sonographer believes she sees versus what the physician thinks he knows.

Great radiologists and reading physicians will critique a sonographer’s images and call them out on sloppy pictures. Sonographers will defend their opinions and their patients when a doctor minimizes the seriousness of the findings with a list of differential diagnoses or refuses to discuss the diagnosis with the patient. This happens in real life.

Tip #2:  Sonographers turn off the sound of the heartbeat.

In the famous Doritos commercial, granted the scene is a comedic parody, but if you listen close during the entire exam, the heartbeat is playing in the background and there is no Doppler technology activated. This is also the case in many television scenes, depicting actual exams.

In real life, the heartrate sound does not play during the entire exam. Sonographers know the heart rate plays only when we turn on the Doppler technology, drop the gate into position and hit the update key. We listen for a few seconds, acquire a heartrate strip along the bottom and then turn the sound off.

For writers: If there is background noise, it comes from the cooling fan on the machine.

Next post: Tips #3-#5.

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Shannon Moore Redmon writes romance 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.

Author Beware: Movie Patriots Day and Narcotic Distribution

Recently, I took in the movie Patriots Day starring Mark Wahlberg that follows the events surrounding the Boston Marathon bombing that took place on Monday, April 15, 2013.

The movie is insightful and entertaining and I don’t think I’ll be spoiling anything by discussing it here. Plus, the issue I’m highlighting really has nothing to do with the events of the actual bombing.

Mark Wahlberg plays Sergeant Tommy Saunders. In the movie, he is suffering from some sort of chronic knee injury. He walks with a limp and is looking to get off patrol for this very reason.

In the aftermath of the bombing, he goes to one of the local hospitals to interview witnesses. He approaches the nurses’ desk and asks a nurse for something for pain. The nurse offers Lortab, a scheduled narcotic, but he declines and asks for Tylenol or ibuprofen instead.

Yea— just no.

Even in a disaster, a nurse is not going to be handing out scheduled medication for several reasons that I’ll highlight below.

First, what are scheduled medications? The FDA schedules medications that have the potential to be addictive. Schedule I medications are highly addictive and have no currently accepted medical use— drugs like heroin and LSD. Lortab is a Schedule II medication– which means it’s highly addictive, but does have a medical use. All scheduled drugs in the hospital have a process where they are counted to ensure no one is diverting (not using the medication for its intended purpose) the medication.

Narcotics counts where there is less drug there than should be are taken VERY seriously. Even in a disaster situation, these would be watched closely. The nurse would not be handed a bottle of Lortab to dispense as she wishes.

Why would a nurse not be able to simply give this police officer Lortab in a critical incident where there is a large influx of patients and things are generally crazy?

1. The police officer is not a patient. Any medical treatment rendered by the hospital should be documented. Now, I could see the nurse tossing him a few Ibuprofen considering these circumstances. In all likelihood, this would be frowned upon but understood. Not so with a narcotic.

2. It is outside the nurse’s scope of practice. Scope of practice deals with what a provider can and cannot do. It is generally determined by the state licensing board where the individual practices. Scope of practice issues tend to be a big pitfall for writers everywhere and I’ve blogged about it previously here and here.  A nurse cannot order medication for a patient without a standing protocol in place— this is a provider function. A nurse also cannot dispense medication— this is the function of a pharmacist. Even with automated medication dispensing systems, there is usually a pharmacy double check before the medication can be pulled from the machine. In an emergency this function can be overridden, but that is highly frowned upon.

Overall, Patriots Day was an entertaining film and most probably won’t even realize this error. However, in writing please keep in mind scope of practice issues. Not every medical provider can do every medical function— even during a disaster.