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!

Video on Treatment of Excessive Bleeding

Since I get LOTS of questions regarding bleeding, I thought this would be a nice instructional video to post regarding treatment of excessive bleeding.

The post is mildly political at the beginning and does contain some profanity (bleeped out), but at the end it is a great discussion of controlling bleeding— particularly use of tourniquets.

Thanks ZDogg, MD for the great information and keep up the good fight.

911: Let’s Provide Some Medical Care

In the Season Two/Episode Eight airing of the FOX television show 911— there was a great scene on how to really provide no medical care.

The setup: A gay couple is getting ready to go on a bike ride. Much time is spent in a musical montage showing their lives together. It’s clear they have had a loving relationship and remain deeply in love. One gentlemen goes to load a bike onto a SUV when, in a series of unfortunate events, he gets pinned by the SUV to the entrance gate— akin to Anton Yelchin’s accident (though they do show in the episode the SUV was placed in neutral).

He is discovered by his partner who then calls 911. Upon arrival, there isn’t much done for his lover. He is essentially declared dead on arrival.

Then, the gentleman who discovered his partner, goes unconscious while a firefighter has his back turned. Literally only a few seconds have expired when the firefighter discovers he’s passed out. They provide one and a half cycles of CPR and kind of shrug their shoulders declaring that he’s died, too.

This is unacceptable management of this patient. It’s essentially a witnessed arrest so they were correct to start CPR immediately, but at the very least, he should have been connected to an AED for rhythm analysis and probable defibrillation. A very common reason for sudden collapse are arrhythmias that will respond to electricity. There’s no reason why this gentleman’s treatment  should have been so sparse. It would have increased the drama and the tension of the episode to have this patient get a full resuscitation.

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.

 

Author Question: Treatment of Teen Suicide Victim (1/2)

Pink Asks:

Hi there! I’m so glad I’ve found your site and thanks for taking the time to read this. Ok, here goes.

I’m writing about a fifteen-year-old boy who is being abused physically and sexually by his father. One day at school, he tries to commit suicide by slitting his wrists. He becomes scared by the amount of blood, so he leaves the restroom to try to find help. He is found by his teacher and passes out. Now, I know with any kind of suicide attempt, the police are always contacted, and given the all clear for the paramedics.

Jordyn: I think it would depend on the city, county, school district (and whether or not there was a school resource officer) as to the level of police involvement if he just really needs medical attention. I would advise that if this is written about a real place you ensure they have co police response because a paramedic team would be able to handle this call.

Pink: What will the ED staff do to stabilize a patient who has slit their wrists? Is surgery necessary if the wound is pretty deep?

Jordyn: We always look at airway, breathing, and circulation first. If the patient is talking to us then we can quickly check off the first two as at least functional for the time being. As far as circulation the priority is to stop all active bleeding first by direct pressure. Also, does the patient exhibit any vital sign measurements that show he’s suffering from blood loss—which in this case could be increased heart rate, low blood pressure, and also low oxygen levels.

After that, the medical priority for this patient is to further control the bleeding and determine how much blood he’s already lost. Direct pressure is the method used to control the bleeding. Blood work would be done to look at his blood counts to see if he needs any blood replacement. Next would be to look at if he damaged any arteries, tendons, ligaments or nerves during the attempt. Generally, an exam of the function of the fingers can reveal if there is a concern there. For instance, do his fingers have full range of motion? Do any fingers have areas of numbness? Arterial bleeding is very distinct so it’s usually obvious if an artery has been severed. If he has damaged anything that would limit the function of his hand then he would need follow-up evaluation by a hand surgeon for surgery. If there is no damage to the structures as listed, there is a possibility the wound could be closed in the ER as a simple laceration repair.

Pink: Upon discharge, what will the patient be given to take home for treatment of their wound (the slit wrist)?

Jordyn: If the patient gets a simple laceration repair (merely closing the skin even if it takes a lot of stitches) then pain could be managed at home with over-the-counter pain relievers like Tylenol or ibuprofen. If the patient requires surgery, a short course of a narcotic may be given for pain control,    but we also have to look at other factors to determine if this would be wise for the patient (are they a current drug addict or is there continued concern for suicide attempt). If the patient has surgery, then it is up to the surgeon to determine the patient’s home pain relief.

Pink: If a nurse or doctor notices any bruises on the patient’s body, can they examine an unconscious patient?

Jordyn: Yes, an unconscious patient’s skin can be externally examined. In fact, it is often protocol to do so because we are looking for clues as to why the person is unconscious.

Well continue this discussion next post.

Medical Review of the Movie Flatliners 1/2

Flatliners 2.0 released in October, 2017. If you haven’t seen the movie (or the original from 1990) then you may not want to read this post as there will be spoilers involved.

Flatliners centers around a group of medical students who become curious with the phenomenon of near death experiences (NDEs) to the point that they “flatline” one another so that they can purposefully have one.

This first post will deal with a medical scenario that happens in the first ten minutes of the film. We’ll look at two screenshots from the movie.

Here is the conversation among the medical students when their new patient arrives.

Paramedic: “Transfer from Holy Cross. Thirty-eight year old construction worker fell off a beam. Persistent coma. GCS 6.”

Marlo: “Standard procedure for a GCS 6 admit calls for 2 large bore IVs and diazepam on standby.”

Ray: “Seizure meds won’t do any good. Whatever is wrong is in his spinal column and not in his brain.”

Marlo: “And what medical protocol are you citing?”

Ray: “The protocol of actually living in the real world. Where guys with crappy HMO’s go undiagnosed with spinal injuries.”

Marlo: “Actually he’s on seizure meds which is a medical protocol of reading his chart.”

 

At this point an alarm sounds and the students begin to panic. This is the screen shot at the moment of panic. It shows the monitor. The patient’s heart rate is a nice steady 73. His oxygen level is 100%– can’t get any better than that. His respiratory rate is 19– the patient is on a ventilator. I don’t know– things looks pretty good to me for this patient.

An attending doctor arrives.

Attending: “What is it?”

Student: “Respiratory failure.” (Based on the screen shot, there is no basis for this. Also, nothing is quite hooked up correctly at the head of the bed for an ER.)

Attending: “He might be hemorrhaging. Page neurosurgery, call a code, and get CT on standby. Students, clear the room!”

They then show another monitor in the room which appears to show ventricular fibrillation (V-fib) which is a lethal, but shockable rhythm. Yet, no one starts CPR.

End Scene.

Issue #1: I’m not sure how a medical student within the first ten seconds of getting this patient can know if the problem is in the brain or the spinal cord. For me, the problem seems likely to BE in the brain considering his persistent vegetative state.

Issue #2: Because of the patient’s insurance, he didn’t receive an accurate diagnosis. Mmmm . . . I know this myth get’s perpetuated. You don’t necessarily need expensive tests ALL the time to get an accurate diagnosis. CT scans and MRI scans aren’t really seen as extreme measures anymore. Though they are expensive the cost has come down.

Issue #3: Nothing these medical people say makes any sense medically. What evidence is there that the patient is in respiratory failure? The photo of the first monitor doesn’t suggest that. What evidence is there that the patient is hemorrhaging into his brain? Fixed and dilated pupils? Unequal pupils? A worsening coma score? None of that is presented in the scene.

Issue #4: The one medical problem they seemingly show is the V-fib in the second screen shot. Good to call a code, but research has shown that early and effective CPR is the one thing that is best at bringing people back. The next is early defibrillation which no one seems to anxious to accomplish.

Is it that hard to find good medical consultants for movies?

This Is US: Jack’s Needless Death

This television episode caused more people to reach out to me over any other. This Is Us has been building up to Jack’s death for eighteen months. It needed to be big. It needed to be dramatic. Can you tell I’ve been watching the show? It was really none of those and medically— well, just weird to be honest.

If you haven’t watched the episode then don’t read this post because it will reveal his cause of death . . . like right now.

Jack’s ultimate demise? A heart attack called the widow maker caused by the stress of the fire.

Jack is in intense smoke and heat for several minutes. He emerges and is first checked by EMS. He is being given oxygen and a dressing to his arm for “2nd degree burns”. The EMS person says she can’t treat the burn and he is seemingly refusing transport, but she does encourage him to be seen. Also, giving oxygen is correct, but it is not the right type of mask. A note on burns. Burns will evolve over the next several days so you don’t really know how severe a burn will be for a while.

Jack does eventually go to the hospital to get his burns checked. The doctor is initially giving him instructions on burn care.  The doctor says, “I’d like your heart rate to come down.” and glances at the monitor— which doesn’t have any readings on it. No waveforms. No numbers. He then says, “There’s soot in your airway so we’ll have to run some tests. The swelling is minor.”

That’s about it. The doctor tells Jack he basically dodged a bullet and seems none too concerned about his potential airway damage.

Just as I mentioned above, airway burns from smoke inhalation are similar to skin burns in that they evolve over time. Smoke inhalation and the potential for upper airway swelling is taken very seriously. There is a nice overview here. At the very least, there should be discussion of admitting Jack to the hospital. As quoted from the article, “Studies have shown that initial evaluation is not a good predictor of the airway obstruction that may ensue later secondary to rapidly progressing edema.” If there is concern about significant injury to the airway then the patient is electively intubated until the airway injury heals. It’s VERY difficult to intubate someone with a lot of airway swelling.

Shortly after this consultation, Rebecca decides to make a phone call and get a candy bar from the vending machine. In that, perhaps under two-three minutes passage of time, Jack codes and dies. Even though she is just outside the ER nurses station, she never hears a code being called. Doesn’t see the commotion.

The doctor approaches her and says, “One of complications of smoke inhalation is that it puts a terrible stress on the lungs and therefore the heart. Your husband went into cardiac arrest. It was catastrophic and I’m afraid we lost him . . . Mrs. Pearson, your husband has died.”

After a few exchanges she goes to Jack’s room where there is a spotlight shining on his chest with a cursory ambu bag at the head of his bead . . . but no other equipment. I’m telling you in two minutes, a code has barely just begun and is never called so hastily . . . like ever. Later, explaining the event to Miguel, Rebecca says he had a widow maker’s heart attack.

The widow maker is a real term for a heart attack. It generally refers to occlusion of the left main coronary artery that feeds the left side of the heart. It is the same heart attack celebrity trainer Bob Harper had and survived. The reason the widow maker can be so devastating is that the left ventricle is the largest, strongest pumping chamber. If it dies . . . well, you’re hosed.

There would be no realistic way the doctors would know it was specifically this kind of heart attack as shown in the episode without an autopsy. Presumably, Jack went into one of the lethal heart rhythms, v-tach or v-fib, at the time of his code. In the time frame given on the show, the medical team would have barely started CPR and given the first line treatment which is electricity. A 12-lead ECG can be a strong diagnostic tool for this type of heart attack, but they never did one. Had they done that early on, they probably would have seen the changes.

Also, he would likely have some signs and symptoms. Chest pain. Nausea. Left arm pain. Sweating. Demonstrating these might make the scenario seem more believable. Having Rebecca witness the code would have been more dramatic.

Also, it would make more sense that he would suffer this cardiac event while he is actually under duress— such as during the rescue of the children and the dog.

The only way to truly know that this is the type of heart attack Jack suffered as presented in the show would be to conduct an autopsy.

This Is Us— thanks for killing off a beloved character in a totally lame way— at least from a medical standpoint.