New Amsterdam: Prioritizing Epinephrine Over Oxygen

New Amsterdam is a new medical drama on NBC this year. You can see my first post about it here. Today, I wanted to review a medical scenario with you and the problems with they way it’s presented.

As I discuss the scenario remember that all medical providers are taught this from the very moment they step into medicine: A, B, C— Airway, Breathing, Circulation.

Here’s the setup: A man travels from Liberia where he begins to exhibit signs of Ebola. They place him in isolation (a good move). A big lecture is given by Dr. Max Goodwin, the new medical director, that no one is EVER to enter the isolation room without the proper PPE (Personal Protective Equipment). From there, it gets a little bit strange.

The first issue is that it’s stated that the isolation room is “stocked with every available medication should the patient need to self medicate.” A few problems. A sick and deteriorating patient is going to have the wherewithal to find a drug and give it to himself? This is later proven to be a bad idea when the patient can’t even reach for an easily accessible oxygen mask without falling out of bad.

Also, everything in the isolation room is going to get thrown out and likely charged to the patient so for a medical director who is so concerned about minimizing costs for the patient . . . well, you can see where I’m going with this.

The patient begins to cough up blood, bleeding profusely from his mouth, and has difficulty breathing. As the doctor is getting into her PPE, she instructs him to give himself oxygen which he is unable to do and then falls out of bad. Without getting into full PPE, she enters the room to help.

I actually like this aspect of the show. As I’ve said all along, medical people can make bad choices, as long as the writer shows repercussions for them which they do in the show.

The doctor immediately begins to work to aid his breathing. This is the right choice. She believes the airway is too obstructed so she immediately moves to a needle cricothyrotomy. This is generally done as a rescue measure when other attempts to secure an airway have failed— it is not the first choice.

However, as the doctor inside the isolation room is generally doing most of the right things, Dr. Goodwin (the new medical director) is telling her to give the patient an IV dose of Epinephrine before she gives him oxygen. He tells her to prioritize the epinephrine over the oxygen. At the screen shot to the right, what’s obvious is that the blood pressure (82/40) is low and that the patient’s oxygen levels are REALLY low at 64% (normal is generally considered above 90%).

There really isn’t an indication for epi IV (as in a code dose) in this scenario. The first two reasonable thoughts for this patient’s low blood pressure are sepsis (low blood pressure caused by overwhelming infection) and blood loss from the obvious hemorrhage. Epi can be given in this situation (for low blood pressure related to sepsis) as a continuous drip, but not as a push medication.

Most importantly in this situation, epi would not be prioritized over the patient’s alarmingly low oxygen levels.

911 S2/E2: Determining Death

In Episode 2 of this season’s Fox series 9-1-1, a devastating earthquake has hit LA county.

The team is searching for victims when they come upon a patient where only her lower legs are visible. The paramedic reaches down and assesses her pulse at her foot and determines that she’s dead. Time to move on.

Can you feel someone’s pulse in their foot? Yes, you can. He’s palpating what’s called the dorsalis pedis pulse.

Should it be used to determine if the patient is dead? To this, I would say no. The problem is, when the body goes into shock, it shunts blood toward the central aspects of your body to ensure blood flow to your vital organs so even though the person is alive, you may not be able to feel the pulses in the feet. This is why when checking for life, the use of central pulses is encouraged— for instance the femoral or carotid pulses. Also, this victim could just have two broken legs with compromised blood flow to her feet causing the lack of pulse.

However, I’m not going to give them too much grief for this. In a mass casualty situation, sometimes you do just need to move on and save who you can.

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.