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03/02/2018

BioethicsTV (February 26-March 2): #TheResident, #ChicagoMed, #TheGoodDoctor

The Resident (Season 1; Episode 5): Concurrent surgeries and medical errors
The Good Doctor (Season 1; Episode 15): A murderer’s liver; and an externalize heart
Chicago Med (Season 3; Episode 10): Child-bride

by Craig Klugman, Ph.D.

The Resident (Season 1; Episode 5): Concurrent surgeries and medical errors

This episode begins in a morbidity and mortality conference where three patients cases are presented. We then flash back 12 hours earlier when all 3 patients enter the hospital for ordinary procedures—rectal extraction of an object, orchiectomy, and stable abdominal aortic aneurysm. The CEO has a meeting with all of the chiefs urging them to book ORs to capacity—unused capacity is money left on the table. Ideally, she urges them to have concurrent surgeries. In this method, a single surgeon oversees multiple surgeries at one time. The actual surgeries are done by residents and surgical staff while the attending moves from room-to-room. One of the chiefs, Dr. X, argues against this method, saying that it splits focus and provides too much room for error. Dr. Bell used to use this method, but has stopped since he began having tremors (which he keeps hidden). The CEO encourages him to start doing concurrent surgeries again.

In reality, this method came to public light in a June 2017 Boston Globe Spotlight article that found concurrent surgeries happening at Mass General: “Orthopedic surgeons at Massachusetts General Hospital repeatedly kept patients waiting under anesthesia longer — sometimes more than an hour longer — than was medically necessary or safe, as they juggled two or even three simultaneous operations, according.”

For the first surgery (extraction), Bell recruits a surgeon just completing a 36-hour shift who is falling asleep on his feet. Of course, this could not happen because ACGME duty hours mandate that a resident cannot work more than 24 hours in a row without an 8 hour break between shifts.  When he falls asleep during the surgery, he nicks an artery and the patient bleeds out quickly. Bell pulls Okafor, his star resident, from a second {the orchiectomy) surgery (thus leaving a patient on the table, open, and under anesthesia) to repair the damage. Okafor is then pulled into a third surgery when that patient’s aneurysm blows and is moved into emergency surgery. Why is there only one person in the hospital who can perform surgeries, and a resident at that, is a bit mysterious when other surgeons and surgical residents are walking around. This is not actually  concurrent surgery where 1 attending is overseeing multiple surgeries being done by residents but rather 1 resident performing 3 surgeries.

In the return to the morbidity and mortality, we learn that Okafor removed the wrong testicle (first surgery) in part because when she returned to her original surgery she forewent a second time out, fearing the patient had been under too long. All three patients survived. We move to Bell apologizing to the orchiectomy patient and immediately walking into the CEO’s office. The CEO asks, “How was the apology received?” They then cite statistics of how an apology diminishes the likelihood of a lawsuit. The problem, in their shared opinion, wasn’t the concurrent surgery, overworking residents, or only having one working surgeon, but that a physician questioned Bell and his method in the M&M about the concurrent surgeries. They fire Dr. X.

The Good Doctor (Season 1; Episode 15): A murderer’s liver; and an externalized heart

A child rejecting his liver transplant acutely needs a second transplant. He’s a rare blood type and finding a match will be difficult. However, there is a person of the same type who wants to do a direct donation. The donor originally made this offer to another patient who died before the procedure could happen. The one twist is the donor is a prisoner who murdered 7 people. In an “ethics meeting” we learn there is no law preventing the donation but there is liability if the donor should get loose in the hospital and tries to escape. One pro argument is that perhaps the donor wants to make amends. A second claim is that perhaps the prisoners owes a debt to society for his crimes. The chief of surgery is concerned whether this creates a slippery slope of allowing people to sell their organs. They reach no agreement. The child, however, does not want a murderer’s liver in his body, fearing that personality traits will follow with the organ. Further discussions emphasize that a child does not consent to surgery so what the boy wants does not matter. What they are neglecting is that while the parents consent, the child assents.

As the story continues, the donor is allergic to (all) anesthesia and the surgery must be canceled. However, the donor has a great need to save a life and so when he is being brought out of the prison he grabs the guard’s gun and shoots himself in the head. The result is that the living donor became a dead donor and his organs could be used to save other’s lives. The boy gets his liver and the rest of the organs are distributed through the UNOS system.

In a second storyline, a young teenager has a condition where she was born with her heart outside of her chest. Normally, surgery would have occurred when she was very young, but in her case her chest was too small. Now that she has grown, there should be room. However, we learn that her heart is still too big to fit into her chest. Because of her condition, she has never been hugged, never been a in crowd and rarely leaves the house. A resident suggests an experimental absorbable plate could be used to craft an artificial rib cage that would allow the surgery to go forth and could grow along with the patient. The surgery is successful and she is able to get a hug.

In a small third storyline, CEO Aoki is wooing a donor and later explains to Andrews that she thought there was a spark. Aoki asks, could she date a potential hospital donor (and city councilperson)? She says that he is not a hospital employee and there is no policy against it. Andrews says the problem is the optics, that it creates a perception of her using sex to get a donation. While there is no violation of a policy or law, there is an ethics problem: Conflict of interest. Despite the advice, Aoki asks the potential donor out anyway.

Chicago Med (Season 3; Episode 10): Child-bride

A reverend from out of state brings Lindsey, a 14-year-old pregnant girl, to the hospital with nausea and bleeding. She has miscarried with some irregular readings. When the doctors ask him to step outside to give his daughter some privacy, the Reverend informs Halstead and Manning that the girl is his wife. This leads to a consultation with hospital counsel who determines the marriage was legal because the father signed off on it. Although this marriage would not have been legal in Illinois (where the show takes place), the lawyers says it was in Michigan {However, even with parental permission, the legal age for marriage in Michigan is 16). . Manning is furious and wants to have the Reverend arrested, but legally he has done nothing wrong even if one finds a middle-aged man marrying a 14-year-old morally repugnant. The girl has an early-stage uterine cancer and Manning recommends chemo. If that fails then a hysterectomy might be necessary. The Reverend rejects both options because they could affect the girl’s fertility. When Manning asks him to leave the room he refuses and states that his wife wants him to stay, a statement to which she reluctantly agrees.

In Illinois, marriage is only permitted at age 16 with parental permission, though the age of consent is 17. Also, in that state, the patient could consent for her own treatment because she is a married minor and because in Illinois a pregnant minor can make health care decisions. Manning explains to Lindsey that she can make her own decisions. The Reverend walks in on this conversation and he physically removes Manning from the room. Then he yells at her for treating his wife as a child (even though she is) and he tells the charge nurse, “I want this *$#% removed from my wife’s care.” Goodman meets with the couple who “gave me an earful” and tells Manning that she is off the case.

Halstead busies the Reverend with discharge paperwork and he goes to speak with Lindsey alone. Lindsey reveals that her mother and grandmother died before age 20 from ovarian cancer. She wants a hysterectomy given her family history and her life, “I don’t want to bring a kid into this [her] world.” When Halstead takes her into surgery the Reverend stops them and says that she is not having a hysterectomy. Halstead shows him the signed informed consent document. With a security guard nearby, the Reverend informs her that she will be banished from the church. Lindsey simply smiles as she is wheeled away. The hysterectomy was a radical choice, but given her family history and given that it was her way out of a life she was trapped in, for her, it might have been the right choice with a very high price.

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