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09/28/2018

BioethicsTV: (September 23-28): #TheResident, #NewAmsterdam, #ChicagoMed

by Craig Klugman, Ph.D.

Jump to New Amsterdam (Seasons 1; Episode 1): Infectious disease; mistaken diagnosis; Jump to The Resident (Season 2; Episode 1): Emergency preparedness, risky surgery, and dehumanizing technology; Jump to Chicago Med (Season 4; Episode 1): Deaf culture

This week is the beginning of the new television season and the popularity of the medical drama is evident as a total of 5 prime time dramas hit the airwaves (The Resident, The Good Doctor, New Amsterdam, Chicago Med, and Grey’s Anatomy). In the first week of the season, however, many of these shows seemed to avoid ethical dilemmas, taking a turn toward the personal relationships of the main characters rather than difficult choices.

The Resident (Season 2; Episode 1): Emergency preparedness, risky surgery, and dehumanizing technology

The new season begins days after the last season ended. The gimmick with this episode is a massive power failure when hackers take over the hospital systems. New CEO (the famous surgeon) Dr. Bell (as he reminds someone who calls him “Mr.”) seems overwhelmed at first, but quickly makes decisions to send his staff to deal with the situation. However, he is ultimately concerned about losing money to other area hospitals that still have power. The head of IT says that he had recommended an upgrade systems, but the budget was denied. He recommends paying whatever ransom is requested because that will take less time than changing out the hardware. The perpetrator is a patient, actually a person faking her symptoms because her family has gone bankrupt over paying their hospital bills and she created a virus to wipe out the billing system (that clearly went wrong). For the first time ever, this show offered an accurate warning for hospitals: Given the threats of hacking and of power problems, it is essential to have the latest software and hardware protections; and emergency generators need to be functional and fueled. This is a basic part of emergency preparedness and it’s a matter of when, not if.

In one storyline, newborn baby Mabel has hypoplastic left heart syndrome (the left side of the heart does not develop normally). After the power failure, resident Okafor and attending AJ Austin estimate they have 34 minutes of reserve power to complete the surgery because if they close up now (which protocol requires) then Mabel will die. If they continue, they estimate a 50-50 chance of survival. They choose to continue. Before emergency power dies, Austin gives his team a “pep talk” which feels more like bullying and berating (though that could be my interpretation after a day of watching The Kavanaugh-Ford hearings). Although they violated hospital protocol, the 50% chance of success does seem like the more ethical move than a certainty of an unwanted death.

Although the following scene was a brief moment, it struck me as a poignant commentary on the automation of medicine which supposedly creates efficiencies but simply ends up dehumanizing medical care: When the computerized pharmacy stops working, Nurse Practitioner Nevin takes a crutch and breaks open the glass panel. Another nurse says that they should bust all of the machines, “Maybe then we could look patient’s in the eye again.” She is referring to new protocols that have health care providers entering data into the computer and thus keeping their eyes on the screens, rather than being inefficient and looking patients

New Amsterdam (Seasons 1; Episode 1): Infectious disease; mistaken diagnosis

In this new show based on the book, Twelve Patients: Life and Death at Bellevue by Eric Manheimer, who is also a producer and writer on the show, Dr. Max Goodwin (we already know that he is a good guy because his name says “good” and that he will “win”) is the new medical director at New Amsterdam Hospital (a.k.a. “The Dam”), the country’s first medical hospital, prison hospital, and an academic medical center where everyone is treated, even if they lack medical insurance. On his first morning, Goodwin fires the entire cardiology department because they put billing above patients (they also have the highest mortality rates in the city). He wants to stir things up and put patients and care first. This is another in a series of shows (e.g. The Resident) that begins with the premise that medicine is broken and non-physician administrators are the problem. We learn that not only is he a medical director who wears scrubs and a lab coat, but he is also a cancer patient himself—squamous cell carcinoma.

A patient walks out of the airport carrying two shopping bags and asks a cab to take them to New Amsterdam. After waiting in the ED, they collapse. As the patient is being wheeled through a hallway, a nurse finds a boarding pass from Liberia. Dr. Bloom has everyone move away and don masks because the patient has signs of Ebola. While Goodwin’s specialty is not clear,  he does give orders to direct the response to this patient. Homeland Security views the patient as a terror suspect since they received word of a plot to send an Ebola-infected person to Times Square. The patient crashes and Bloom skips putting on her biohazard suit to help the patient. (Which raises the question of why no one was partially suited up at all times—often a standard procedure since proper suiting can take 30 minutes). It also raises the question of this choice since Bloom won’t be able to help other patients now for 21 days while she is observed for symptoms, and that her infection is likely when a torn glove shows blood on her skin. But, in a deux ex machina moment, the patient has Lassa, which is treatable, not Ebola and Homeland mysteriously lets the person go.

In another storyline, a woman is brought into the ED, dead. But really, she is in a catatonic state as a result of mis-medication and a tumor. We learn that she was misdiagnosed with Parkinson’s but has a heart tumor. Goodwin tells her they can provide treatment but it won’t help and “this is a case where the treatment is worse than the disease”. He suggests that she might have other ways to spend her limited remaining time. One of the challenges of modern medicine is that there is usually something that can be done and it is not common to pull back and ask if we should be doing that something. This frank conversation allowed the patient to assess her values and desires for a quality at the end of life that met her needs—in her situation, to go home and spend time with family.

Chicago Med (Season 4; Episode 1): Deaf culture

A patient comes to the ED one month after cochlear implant surgery. His fiancée, who is also deaf, fears he has an infection from the surgery and is against him turning on the device. Halstead and Manning quickly determine that he does not suffer from an infection. The fiancée breaks off the engagement, thinking that his being able to hear will take him away from her and deaf culture. When it turns out he has Usher’s, we learn that he is losing his sight. The fiancée returns saying she loves him. She supports him and when his implant is activated she says that she will be his eyes. While there is not an ethical issue in this case, it does present a clashing of cultures and how to handle them. Having an ASL interpreter in the ED was a big step in enabling good health care provider-patient communication. And while the doctors spoke slower (to allow the interpreter to sign), they spoke directly to the patient and treated him as any other patient.

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