Hostages

Hostages: Episode 8 Analysis 3/3

/ Jordyn Redwood / Leave a comment

Over the past several posts I’ve been analyzing the CBS drama Hostages. These posts have concentrated on one particular episode and here are Part I and Part II.

Ellen discovers that the primary hostage takers wife is a patient at another hospital and she gives her one of the other captor’s the slip and proceeds to go over there and snoop.

The primary hostage taker’s wife is dying of cancer and desires for all treatment to stop. Her husband has begged her to press on and try one more round of chemo for the sake of their elementary school aged daughter.

Ellen finds the ill wife and she happens to be sleeping and begins to read through her chart that is located on a clipboard at the end of her bed.

Problem #1: This is a plain and simple HIPAA violation. Patient information is highly guarded and there is no way that much information is going to be out in the open for public consumption. Anyone could grab it– from our snooping doctor to housekeeping and if you aren’t directly caring for the patient then HIPAA says you have no reason to view the patient’s healthcare information.

The patient awakens and sees Ellen there. She assumes Ellen is a doctor her husband has hired to consult for an experimental medical treatment related to her cancer. Ellen wants her to go back to sleep so she grabs the patient’s PCA button and depresses it about three times and within five seconds (I counted) the patient falls quickly back to sleep.

Problem #2: Let’s just classify this section as PCA pumps in general.

A PCA pump (Patient Controlled Analgesia) functions to let the patient decide when they need pain medication. They allow the patient to stay on top of their pain before it gets out of control where it can be more difficult to temper down. They can deliver a basal rate (a small amount of medication all the time), a PCA dose (which is a bolus dose of the medication the patient decides when to self administer) or a combo of these two.

PCA pumps have safety mechanisms. The patient can only give themselves one dose every several minutes. Generally, it’s between 8-10 minutes. When our good doctor gives three subsequent doses– this is not medically feasible. No PCA pump would allow a patient to deliver that much for fear of overdose. Pumps are never set that way.

The other issue is how quickly the patient falls to sleep. IV morphine does work quickly but not THAT quickly.

Eventually, Ellen is discovered by the primary hostage taker. With her back turned to the PCA pump she is able to unlock the door and grab the syringe and threatens to inject the whole thing into his wife– thusly killing her.

Problem #3: PCA pumps are ALWAYS locked and doctor’s never have a key (unless you’re an anesthesiologist.) This is another safety feature of the pump for this very reason– we don’t want anyone accessing it and thereby overdosing the patient. The person in possession of the key would have been her bedside nurse. Newer pumps could have a key code for access.

Hostages: Episode 8 Analysis 2/3 and Snake Bite Kits

/ Jordyn Redwood / Leave a comment

This is part two of three in analyzing ONE episode of the CBS drama hostages. You can find the first part here.

Last post I blogged about why a paralyzing agent wouldn’t kill a person during surgery.

Now, let’s examine why Ellen’s treatment of the injected poison is suspect as well.

When we left him, our primary hostage taker had a needle full of the paralyzing agent stuck in his chest but only a small amount had been given. He was symptomatic as evidenced by some weakness.

The good doctor says, “We need to cut it out.”

She then proceeds to remove the syringe, slice open his chest in the area the needle was, and then thrust his entire body in ice water. 

This reminded me of a first aid kit I used to have that had a snake bite kit in it and it looked just like the photo. The green thread is supposed to function as a tourniquet to keep the poison from traveling. The ampule is iodine to clean the area. The blade is used to cut an “x” through the skin and the green plastic parts are to extract the poison. The rational behind this treatment was to get the poison out before it entered the bloodstream. I guess the rationale for thrusting the hostage taker in ice water is to slow his metabolism down to prevent the poison from traveling as well.

This method of poison extraction has been proven false. Poison or infectious type agents can rapidly enter the bloodstream and in fact, some have postulated that cutting the skin increases blood flow to the area and hastens absorption. As this article also explains that studies show the commercially available suction devices remove “virtually no venom”. 

This article also discussed icing the site– again the rational being slowing the metabolism will keep the venom from traveling but what can happen is that you get frostbite injury from the ice and it may concentrate the poison in one place causing more tissue damage.

What would have been more believable would have been to have him suffer the effects of the paralyzing agent and Ellen, the good doctor, needs to decide whether or not to resuscitate him. That would have been more more dramatic.

Clear here for more information on the current treatment methods for treating snake bites.  

 

Hostages: Episode 8 Analysis 1/3

/ Jordyn Redwood / Leave a comment

Seriously, medically speaking, the CBS drama Hostages is becoming that car accident I can’t avert my eyes from. This episode had me doing some serious eye rolling– one of my eyes may have actually rolled away from me at one point. I have since recovered it so don’t worry.

During episode 7– the husband is left alone with the primary hostage taker and his primary goal is to do him in. What remains in the house is the “colorless, non-traceable, fast-acting poison” that was contained in a lipstick holder for Ellen to give the President during surgery.

Hubby finds it, a needle and syringe and draws up the medication. At the end of this episode he manages to put it into his chest and pushes in a little of the medication.

Enter the hero doctor who is now convinced that he must live or all of her family will die.

She asks him, “What is the poison?”

He says, “A rapid-acting paralyzing agent.”

At this point, I’m going to beg the producers of this show to either get a new medical consultant or hire one. Because, whoever is advising them doesn’t know anything about WHY this wouldn’t kill the president during his operation.

Paralyzing agents don’t stop your heart from beating. I’ve blogged here before about the unique characteristics of heart cells. They have their own automaticity. Paralyzing agents work at the neuromuscular juction to stop the muscles from being able to contract. Your heart muscle is different from this system but your diaphragm is not which is the primary muscle used for breathing.

The reason a paralyzing agent will kill you is that it stops the contraction of your diaphragm muscle and therefore you stop breathing. Obviously, if you’re not breathing you’re going to die so to save your life we have to provide rescue breathing and preferably oxygen.

In surgery, especially the type of surgery the president is having which is a lung surgery, he is already going to be intubated and bagged with oxygen to keep him alive. The injection of a paralyzing agent (of which he may already have some on board to get him intubated) would have a net ZERO effect.

You can read more about neuromuscalur blocking agents here. 

So– it is fiction people and someone in the military wants him gone. You can’t invent an odorless, rapid-acting, undectable poison and give it a cool name?

Part II we’ll continue with the good doctor’s treatment.

Medical Critique Hostages: One Episode to be Thankful For

/ Jordyn Redwood / Leave a comment

Okay, I admit it. I’ve been beating up on the CBS drama Hostages. So– since it is Thanksgiving and we’re to be thankful I’m going to give a shout out to Hostages for one accurate story line.

Then it will be back to a hard medical critique as there is MUCH to discuss in some of the most recent episodes.

In one of the minor plots, the teen daughter is, of course, pregnant. Her father takes her to an OB/GYN to check the status of the pregnancy and stays in the waiting room.

Accurate portrayal #1: Teens presenting for care related to reproductive issues or sexually transmitted diseases are treated as adults in the sense that they don’t have to have a parent present to consent for treatment and should be seen privately by the physician.

During the exam, the physician asks her what all the bruising is about. And, the teen girl does have a suspicious bruising pattern.

Accurate portrayal #2: Suspicious bruising patterns are those that:
1. Can’t be explained by the history given (I fell down the stairs.)
2. Are located over non-bony prominences. This teen presented with bruising to her upper arm (from being grabbed) and to her back (from cutting out a tracking device.)
3. Are numerous and extensive.

The doctor becomes suspicious and notifies social services.

Accurate portrayal #3: A physician is a mandated reporter under most state statutes to report a suspicion of abuse. They don’t have to know beyond a shadow of a doubt that something is happening but if, in good faith, they are concerned by what they see then a report is necessary.

In a few days the teen is approached at school by a county social worker for questioning.This occurs in episode seven.

Accurate portrayal #4: There would definitely be an evaluation of the teen in private– away from the parents. The social worker also interviewed the brother, who also had a black eye. Alone. In psychiatric situations involving teens the family is generally interviewed together and at some point– each member is interviewed alone to get what’s really going on.

So on this Thanksgiving Day– thank you Hostages for accurately portraying management of a family when there is concern for abuse.

Now everyone– have a safe and great holiday. I’ll be working the ER and I don’t want to see you ;)!!

Medical Critique: CBS Drama Hostages 2/2

/ Jordyn Redwood / Leave a comment

This week, I’m medically analyzing the CBS drama Hostages. In the previous post, that you can find here, I said I’d give them some kudos . . . and I will . . . I promise, but it will come at a later time because I’m having too much fun dissecting this episode.

These posts do have spoilers . . . you have been warned.

Last post I discussed the first three issues I had with the episode and they are as follows:

1. Gunshot wound victims are at high risk of dying from blood loss– not heart arrhythmias.
2. Physicians don’t carry hospital grade defibrillators in their back pockets. Maybe Tom Cruise does but I digress . . .
3. Physicians are generally not comfortable operating a defibrillator. This is generally a nursing function once the physician prescribes the amount of electricity he wants delivered.

Onward we go.

Issue Four: After the husband is “brought back to life” Ellen, played by Toni Collette, goes about diagnosing his problem. Keep in mind she’s a cradiothoracic surgeon. Now, she will have gone through a general surgery rotation but her specialty will be everything above the diaphragm.

Her husband has a wound to the left upper quadrant of his abdomen. She sticks her finger into the wound– perhaps up to the first knuckle and declares, “Your renal vein has been severed.” or something relatively close to that.

Wow. Just . . . wow.

Your kidneys lay in your mid-lower back. I like the image here a lot and it comes from the noted website. I think this website is AWESOME. There aren’t any gory pictures but it has several photos of drawings similar to this one that shows the anatomy as it lies under the skin drawn with ink.

This is how we think in medicine. We say . . . “The patient was shot here . . . what is underneath or along the tract that could be damaged.” And from that we order labs, x-rays and advanced imaging like CT.

In reality, there is no possible way to diagnose a renal vein severing with a finger probe to the front of the abdomen . . . or to the back of the abdomen. This needs advanced imaging techniques. Now, there is some gross (not as in yucky) techniques that could likely lend to the diagnosis of injury somewhere along the GU tract. Blood in the urine. Perhaps urine leaking out of a wound. But to be so specific needs advanced imaging.

http://meded.ucsd.edu/clinicalmed/abdomen.htm

And I can’t imagine suturing that vein closed with the patient awake and moving around. Those suckers are small.

I actually do think there would have been a better injury to give this character’s husband that would have been more in her skill set and MORE dramatic and that is the tension pneumothorax.

A tension pneumo could easily happen in a gunshot wound to the chest. The lung is hit and leaks air into the chest cavity. If enough air accumulates in the chest it actually pushes or shifts the chest organs (lungs and heart) to the unaffected side (imagine a balloon blowing up in the affected side.)

Treatment for this type of injury is a chest tube and could be fashioned from something from the home and perhaps something from her medical supplies. You’d need a large size tube– they are big– think maybe 1/2 the size of a diameter of a garden hose and come in various sizes. Once placed, she could secure it with sutures and place the end in water lower than the patient so air didn’t get back into the chest.

To diagnose– you listen to breath sounds. There are no breath sounds on the affected side. Tracheal deviation– which means the trachea is shoved to the unaffected side. There are also temporary measures that can be done until a chest tube can be placed– like sticking a needle in the chest. Then she could have figured out what she needed to fashion a chest tube.

Often times, when I spend time interviewing an expert, I have always come up with a better scenario, and a more realistic one than what I imagined would be good.
  

Medical Critique: CBS Drama Hostages 1/2

/ Jordyn Redwood / Leave a comment

As you know, I’m critically watching some of the new Fall TV shows for medical accuracy. I’ve already posted about the CBS drama Hostages. You can find that here.

This week, I’m going to knock it down but then offer it a helping hand back up. Episode 5 is going to be the brief knock down.

If you haven’t watched all the episodes you have been thusly warned that there will be spoilers in this post.

If you’re not familiar with the show, the President needs an operation and his surgeon, played by Toni Collette, and her family have been taken hostage to force her hand to assassinate him or her family will be killed.

In episode five, the family plots to escape. They end up getting split up. The husband at home. The children on a bus to Canada and Ellen (Toni’s character) almost getting on the bus until she sees video of her husband being shot in the gut.

And, of course, even though he’s a cheating slime ball she goes home to save his life.

Issue One: One of the ways a person who has been shot and is bleeding dies is of exsanguination– meaning all their blood leaks out. The reason significant blood loss kills you is that your body is no longer delivering oxygen and you go into shock/circulatory collapse. What you really need is BLOOD to save your life. Without it– nothing the medical team can do will pull you out from the drain you’re swiftly traveling down. When our trusty surgeon arrives home she finds her husband unconscious and not breathing . . . no pulse.

She starts CPR– yea!! Then asks Mr. Hostage taker to get her medical bag from which she happens to have a hospital grade defebrillator.

Issue Two: There are only a few shockable rhythms. I’ve blogged about the use of electricity here. A likely rhythm for the patient to be in strictly from blood loss is what we call PEA or pulseless electrical activity. There is actually two parts of good heart activity. The electrical component and mechanical component. You need both working appropriately to propel your blood forward and keep you alive. You can actually have normal electrical activity and yet the heart is not mechanically beating– thus the term pulseless electrical activity.

In the case of this character’s husband– his heart likely has normal electrical activity but since he’s lost so much blood– it doesn’t have blood filling the chambers and so doesn’t have anything to pump out. Hence the lack of a pulse.

I’m guessing this husband’s injuries would lead to this set-up. Normal electrical activity with no pulse. So he doesn’t need electricity. He needs BLOOD.

Issue Three: I don’t know any physician anywhere that has a hospital grade defibrillator for their private use. Or would know how to work it . . . quickly. Now, this isn’t a backhanded slap to my physician co-workers. They know how to do their job very well. This just isn’t necessarily in their skill set. Nurses usually set-up the defribillator. The physician orders the desired amount of electricity.

I’ve taught advanced resusitation courses for two decades and I can tell you, across the board, every type of physician struggles to get it programmed. These classes are not a requirement for EVERY physician to take either.

So– wrong treatment with too much ease of use.

What would have been more believable would have been for her to have an AED (automatic external defibrillator) in the home. These are designed for lay people to use and some people do actually have them for home use. They basically diagnose the shockable rhythms and provide electricity if indicated. It’s what many first responders are carrying to even high school settings. They are very user friendly.

Check out my post on Thursday where I’ll continue my discussion of this particular episode.

Fall TV Medical Analysis: Hostages

/ Jordyn Redwood / Leave a comment

Obviously, you know I’m a stickler for medical accuracy– hence the mission of this blog.

Fall TV has started and given me some new shows to analyze. Don’t worry, I’m sure I’ll comment every now and then on a few of my TV staples like Grey’s Anatomy.

Just remember– what you see on TV is not likely accurate. Maybe not even close.

Hostages, which is airing on CBS, actually has a pretty genius medical set-up. The president needs surgery (some type of lung surgery) and wants to increase popularity points by using a “public” doctor who happens to also be a woman.

For some nefarious reason not yet discovered– there are people who want the president deceased. So as a means to this end they hold the doctor and her family hostage until she offs the president during surgery.

Of course, each family member has a secret they’re hiding (except maybe the doctor) which all spills out when they’re in crisis.

The first couple of episodes deal with how the good doctor, played by Toni Collette, saves the president’s life by giving him a complication that will postpone the surgery.

What it shows is her leaving a vial of saline at his bedside. It comes out later that the president was accidentally given Heparin (which is a blood thinner) by a nurse starting his IV and the doctor suspected this when he had some bleeding at his IV site.

And– surgery postponed.

Medically, I have a couple of problems with the scene. The vial the doctor left on the bedside table was sealed– it’s plastic top in place. These can’t be screwed on and off. Once they are popped off, any good nurse assumes that the vial has been used in some way. These can be multiple dose vials (meaning many doses drawn up for different patients) but these days most hospitals used pre-filled syringes or one vial/patient. That particular vial that she left couldn’t have been tampered with because the top was still in place.

I think what would have been more believable would be to show the doctor adding the medication to the vial, and leaving it opened at the bedside and then giving it to the nurse for the IV start versus just hoping the nurse uses it because it’s there.

Also– thinning blood based on one Heparin bolus isn’t that easy to do. Generally a patient is given a bolus and then started on a drip for a period of time.

I do like the show and I’ll keep watching. We’ll see how the medical scenario plays out.