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.

Dear Medical Thriller Author: Please, Ask a Nurse

I just got done reading a recently released medical thriller by a well known author. The novel, overall, was really enjoyable. Truly a captivating story line. However, there is one medical scene that continues to bug me because of the medical inaccuracies that could easily be solved by having a nurse with expertise in the area read over the scene.

In the last three medical thrillers I’ve read, the author always notes the doctors that helped with the novel, but I honestly don’t think I’ve ever heard a nurse mentioned. Trust me, they needed a nurse. Our expertise is in delivering the medical care as ordered by the physician so we know what makes sense and what doesn’t.

In the scene, the patient is suspected of ingesting the poisonous mushroom Amanita Phalloides also known as the Death Cap. The patient has potential political fallout so our hero, a family practice physician, is designated as team leader for this code over two ER physicians. I’ll discuss some of the things I find problematic with the scene.

The hero admits he’s not an expert on mushroom toxicity, but doesn’t phone a friend. One of the first things that should be done in addition to providing for the patient’s medical needs is consulting a toxicology expert (a poison control center is a great place to start). In toxic ingestions of any kind, the medical team needs to know how to counteract the poison. This targeted therapy may be the only thing that will save the patients life. Even if the patient is provided stellar medical interventions, if they’re not given the antidote, it will all be in vain and the patient can proceed to death. That being said, not every poison has an antidote, which then means supportive care.

Let’s discuss these two statements from the novel:

“BP is sixty over palp,” said a nurse, taking the measurement by palpating with her fingertips.
“Pulse one forty-eight by monitor. I can’t even feel a carotid pulse.”

First of all, taking a palpated blood pressure is not usual in the hospital setting. This is typically done by EMS as a quick and dirty measure for obtaining a BP because it is really hard to hear through a stethoscope with sirens blaring above you. Next thing is, one of these two people are wrong. A carotid pulse is considered a central pulse so if it can’t be palpated then the patient is pulseless, has no BP (because you need a palpable pulse to have a BP), and therefore requires CPR no matter what is seen on the monitor. This rhythm is called pulseless electrical activity (PEA) and is treated medically like the patient is asystolic or flatlined. Treatment is high-quality CPR and IV epinephrine, but our hero calls for a central line.

Then there’s this statement:

“Right now, D-five normal saline at two hundred an hour. Wide open.”

D-five normal saline is an IV solution. This is typically not given in a code situation which I won’t highlight here. In reading about this mushroom’s toxicity, I get why the author chose this IV solution, but the reader doesn’t know and so it should be spelled out what the doctor is worried about clinically for this ingestion and how he’s going to treat it.

However, what’s really wrong with this statement is that it is a contradiction in terms for the nurse. Either the rate is 200 ml/hr or the rate is wide open which means the IV bag is let to run into the vein via gravity as fast as it will go. In an adult patient, the IV bag could be delivered in as little as five minutes depending on the size of the IV catheter that’s been placed.

Lastly, this gem:

“Compressions at ten per minute.”

There is a lot wrong with this medical scene (too much to blog about here), but this is by far the most egregious. I read this to my accountant husband and even he knew this was not medically correct. In fact, I googled, “How fast should you do CPR?” and it gives the correct answer without having to click into a web site which is 100-120/minute. This can’t even be a typo because one hundred and ten— can you really mistype that?  Flat out, this is an easily researched aspect and there is prolific information out there on doing CPR.

Dear Medical Thriller Author: Please, Ask a Nurse Click to Tweet
What’s Wrong with this Medical Scene? Click to Tweet

Just as I ask doctors about the medical accuracy of my scenes, so should nurses be asked. Particularly those who are actively practicing in the area.

Fox’s The Resident: Everything Stereotypically Bad About Hospitals (Part 2/2)

Today, I’m continuing my review of Fox’s new medical drama The Resident and all that is bad about it. You can find Part I here.

Let’s continue our list.

THE RESIDENT: L-R: Manish Dayal, Emily VanCamp, Shaunette RenŽe Wilson, Matt Czuchry, Valerie Cruz and Bruce Greenwood in THE RESIDENT premiering midseason on FOX. ©2017 Fox Broadcasting Co. Cr: Justin Stephens/FOX

Bargaining with IV drug users for drugs. In one scene, the younger protege is seen bargaining with an IV drug user so that she’ll give into his demands and it becomes a bartering of sorts like buying food in an open market. Hands down, the physician should decide what his bottom line is and not waiver from it.

Effective CPR is “until the ribs crack”.  Effective CPR is just the amount of compression depth it takes to generate a pulse that can be felt. It is a risk factor that the patient’s ribs can break, but it is not the clinical guideline we shoot for.

An environment of “no questions asked” is dictated. The senior resident gives his junior resident this mantra: “Do what I want you to do. No questions asked.” Again, this type of environment is intolerable in the hospital setting and should never be dictated . . . like ever. A questioning environment has been shown to increase patient safety and smart hospitals are encouraging this very thing. Most hospitals also have a mechanism in place to go above the bedside medical team if family concerns are not being addressed.

A surgical resident get first dibs on the new, bright, shiny, robotic surgical wonder. Need I say more?

The attending surgeon pretends to do a surgery. Remember the new shiny surgery robot? Remember the attending from Part I that has obvious hand tremors and should not be doing surgery? Did I mention this attending surgeon is an ego maniac (he even leaves positive medical reviews for himself)? Well, since no one has ratted out this well . . . rat . . . it must be him that first uses the machine. However, physically, he can’t do it. So he sets up a ruse where it appears he’s doing the surgery where in reality his uber smart, highly capable resident is. I cannot tell you how ethically bad this is on so many levels.

There are several issues that surround a lengthy medical code in the ER. The IV drug user that bargains for drugs in the beginning codes related to a heart infection. She is coded for nearly 30 minutes— the junior resident keeps it going for that long because of his emotional connection to the patient. Of course, just as he decides to call it, the patient gets her pulse back.

The senior resident is mad at him because he’s just revived a “vegetable”. Honestly, it is the senior resident’s job to watch their underlings. There would have eventually been an attending doctor overseeing this code. So, the person least responsible for the length of this code is the junior resident. Everyone higher up on the totem pull has the ability to stop the code.

Hospitals keep vegetative people alive for money. This is so patently false it’s laughable, but is probably more believable for the general public because many think hospitals will do anything to meet their bottom line.

I’ve been in nursing twenty-five years this May. I first started in adult ICU nursing and in that unit in Kansas there was avid discussion of clinical pathways to put people on to withdraw unnecessary (futile) care. In fact, I would say I’ve seen the opposite— at times a push to take people off of life support sooner then may be warranted from both the family and/or medical providers.

A resident taking it into their own hands to discontinue life support. Because the patient has no hope for life and he sees that the family is in no hurry to stop life support, the resident decides to turn off the machines. Fortunately, he is caught by a fellow resident and quickly turns back on the life support and the patient suffers no ill effects. Again, highly unethical. How about . . . having some hard conversations with the family about the viability of their daughter and helping them come to this decision? I know this is painted in the episode as a merciful thing for this doctor to do, but it would have been murder if he succeeded. He does not have permission to discontinue life support and cannot do so on his own accord. Period.

Also, there is no reason to be dumping a bucket of ice cold water onto a patient’s face . . . like ever.

I guess I should be thankful to The Resident for giving me all this blog material. It’s the only thing good about the show.

Tell me what you think of The Resident? If you’ve seen an episode, will you keep watching?

 

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.

Can You Commit Suicide With an AED?

Recently, my husband and I have been binge watching through all five seasons of breaking-bad-s5-400x600-compressedv1Breaking Bad. In the last season, a gentleman decided to kill himself using an AED.

AED stands for Automatic External Defibrillator. It is a quick rescue device used mostly by non-medical people for cardiac arrest. It is designed to recognize lethal heart arrhythmias and deliver a shock (electricity) if the patient is in one. The AED will not always fire. In fact, there are really only two arrhythmias it is designed to treat.

The question becomes, can you use an AED to commit suicide? An AED has two large, white patches connected to the device. In the show, the gentleman places one patch on his chest, pulls off the other patch and places the exposed wires in his mouth. After this, he turns on the device and discharges it, thereby killing himself.

aedThis scenario is highly improbable and here’s why:

1. Both patches must be in place for the defibrillator to analyze the patient’s rhythm. If they’re not, the machine will not progress any further.

2. Let’s say the AED would read the rhythm (one patch on the chest and exposed wire in the mouth)— it won’t deliver electricity for a normal rhythm (which this gentleman likely has because he’s alert and conscious.)

3. Let’s say the AED did fire for his normal heart rhythm— would he die? There is a slight chance that he might die, but only if the AED fired during a very sensitive time in the electrical cycle of his heart which has a very low probability.

All in all, I don’t find this method of suicide possible. Sorry, Breaking Bad, though I did love the series.