Drug Dosing

Why “Poly” Matters: The Perfect Couple (S1E4) and Drug Toxicology Screens

/ Jordyn Redwood / Leave a comment

For a long time, I was an avid medical show consumer– whether it be reality or scripted. The reality based ones, that highlight functioning ER’s, are tolerable. The scripted ones just started to drive me crazy and I haven’t partaken in a medical fiction series in a while. I’ll let you know about my trauma related to watching Rescue: HI-Surg in another post(and I’m not even a lifeguard).

Unfortunately, that doesn’t stop other shows from violating medical accuracy. Why does accuracy matter? It proves to the consumer of the product that you took care to present something close to reality. Our goal should also be to keep them in the story bubble. Any time a reader is pulled out of that magic snow globe, they lose pace and connection with the story.

Which brings me to Netflix’s The Perfect Couple. The basic plot is a woman from a modest background marrying into high society when her best friend, and maid of honor, shows up dead on the beach. The series delves into all the ins and out of who murdered her.

At one point, they show the victim’s toxicology report and I’m including a screen shot of said evidence.

This is hard to read so I’ll give you the details. In the victim’s urine (presumably– the report doesn’t specify) are the following drugs:
1. Zolpidem (Ambien)– sleep agent
2. Polyethylene Glycol– (Miralax)– laxative
3. Diazepam (Valium)
4. Pentobarbital (Barbiturate) Central Nervous System Depressant
5. Alcohol

This report confused me. Why would a dramatic television show reveal the victim was positive for a laxative? Which, by the way, isn’t going to show up on a drug screen.

Then it hit me. My belief is the writing staff really meant this fictitious toxicology report to read “ethylene glycol” which is very different. Ethylene glycol is a highly toxic component typically found in antifreeze. Antifreeze tastes sweet, which is why pediatric patients will continue to drink it if they find it in an open container. It has disastrous effects on the body and can cause death quickly if proper medical treatment isn’t enacted (and even then– it’s dicey).

This toxin also isn’t going to show up on a standard drug screen. The medical team is going to have to look for it specifically and such a niche test isn’t going to be available at every medical center. Also, Ambien is not part of a baseline drug screen.

Wouldn’t it have been more interesting to the plot to have antifreeze found in her system?

What strange things have you noticed on medical show toxicology reports?

Author Question: Drug Dosing in Super Human Metabolism

/ Jordyn Redwood / Leave a comment

Racheal Asks:

I’d love to hear your thoughts on the topic of medicine and dosage within the context of someone with super-human levels of heightened metabolism. Obviously, the concept pushes the question dangerously towards completely fictional answers, but I’m hoping for any input you have at least in the abstract. For instance, would you give the patient more concentrated doses, more frequent doses, larger doses?  What kind of medicines would be prescribed/would correlate with the metabolism bit in context of painkillers and treatment of a gunshot wound?

Jordyn Says:

Regarding your question surrounding metabolism– I think both could be true that the patient may need to receive higher doses and be dosed more frequently depending on the half life of the drug. Fentanyl and Versed could be two of the drugs given for chest tube placement– one for pain and one so the patient doesn’t remember the procedure. These would be given if the patient is fairly stable with good blood pressure. You could look up these drugs and see how fast the peak. Peak time is when the patient will be under the full effects of the medication. From that, you could put in whatever metabolism rate you wanted (2X, 3X or faster) and be able to determine how much more quickly they would need to be redosed on the medication. Also, you could look at the drugs half-life. Half-life is when 50% of the drug is metabolized by your body. You could look at this number, factor in their sped up metabolism rate, to also know how frequently they might need the drug.

You can ususally research this on-line fairly easily by searching for drug information sheets. I’ve included one here for Fentanyl.

I thought this would be a great question to run by Sarah Sundin who is a fabulous author and real life pharmacist. I hope you check out her wonderful historical novels set during WWII.

Sarah Says:

A higher metabolism would lead to a higher clearance — shortening the half-life of the medication. That would mean increasing the frequency for dosing from every twelve hours to every eight hours or every six hours. Often that means an increase in dose as well. Of course, we have to clarify “metabolism.” Some drugs are cleared by the kidneys (renally) and some are cleared by the liver (hepatically) and most are a combination of both. Whatever function you speed up for your character would have to match the primary method by which that medication is cleared.

To research how a drug is metabolized in the body you would search for “pharmacokinetics of Fentanyl” as an example. These articles would help you determine by what method in the body the drug is cleared.

Hope this helps and good luck with your story!

The Good Doctor is Bad Medicine Part 2/3

/ Jordyn Redwood / 10 Comments

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.