Posted on January 27, 2020 at 12:25 AM
Goodwin makes a new policy that no screens are allowed in patient rooms—no tablets, cellphones, laptops, or computers. The reaction from the doctors is fast and furious—”that isn’t possible.” They need screens to document patient information and to know the name of the patient in front of them. Sharpe says that they will have to learn their patients and make an emotional connection, just like they did before there were screens. As is common on this show, it often opens with a big judgement on the medical system: The use of electronic medical records has placed a screen between doctors and patients, a situation that has had a chilling effect on clinical interactions. Depending on the study, doctors spend 26% to 66% of their time charting. While doctors are often complaining about the EMR, in a twist, the New Amsterdam doctors are clamoring to keep the screens at the bedside because they have to complete 36 pages of charting for each patient, most of which is insurance coding information, and requires so much time that to code outside of a patient visit will require them to see fewer patients.
In a second storyline, a Marine comes into the ED unconscious from a motor vehicle accident. During surgery she needs blood, but she has lupus and needs perfectly matched blood, more closely than most people. The problem is that such blood is not available. Sharpe makes some calls and contacts the patient’s fellow Marines who bring synthetic blood to the hospital. This is an experimental use, but we are told is commonly used on battlefields. The blood takes hemoglobin and wraps it in a polymer coating so there is nothing for the patient’s immune system to react to (this is all real but still requires further development). In the show, the application is working and saving the patient’s life. Technically if a drug or device has not been FDA approved, then an emergency request must be filed with the FDA and the manufacturer. In this case, the company is DARPA (i.e. the military) which made the blood available, thus must have approved it. We can only assume that the FDA request was also made. Sharpe tells the patient’s sister the news and she is surprised that they are using something experimental. But rather than protest, she thanks the doctors for saving her sister. However, this sequence of events suggests that the sister did not consent for this procedure. Since the patient was not conscious and no one else was around, the sister is likely the surrogate decision-maker. Given that there was time to get the blood from the military and have it brought to the hospital means there was certainly plenty of time to talk to the surrogate and get consent. This patient’s life might have been saved but she was also subject to a battery.
The ethical theme in this episode was doctors making decisions based on their emotions rather than on their professional knowledge.
In a school bus crash, two young kids are impaled together on a single piece of rebar. One of the kids is bleeding out. Standard protocol is to separate the kids on scene—saving the boy and sacrificing the girl. Marcel tries to save both by not separating—this means potentially sacrificing the boy for the chance to save them both. In the ED they are separated. The girl has a lot of internal damage and loses a kidney. In the CT the boy starts bleeding internally (the rebar damaged the jugular vein). Marcel feels guilty over his previous choice and before surgery chooses to take a more conservative approach. In surgery, Marcel realizes the patient deserves the best care, not just safe care and changes the procedure. Both children make it through their surgeries and it appears that they will do well. Sometimes protocols are arbitrary or were put into place at some point in the past and never questioned. Other times they exist for a reason, like to maximize chances of survival. Marcel made a choice because he lost a child once and thus said he could not stand to see another child die. But ignoring a protocol should be based on good evidence not on dealing with personal demons.
In a second storyline, Barry is a cancer patient who comes to the ED. He has chemo in the same place as Maggie. He passed out from anemia and intermittent arrhythmia. He has a bone marrow donor match for his rare HLA type, but she has the flu and a fever above the cut off temperature. Maggie takes the staff and starts testing them to see if anyone is a match, pulling them away from taking care of the injured children. Goodwin tells her that the greater number of patients need the staff to care for them. The staff returns to work but parents of the school bus kids line up to be tested. The lab finds a match but Barry dies before any transplant can be begun. However, many of the parents turn out to be matches for other patients, whose lives can be saved. Maggie lets her personal feelings toward this patient affect her professional judgement. In an emergency situation that requires a utilitarian perspective, she tries to focus everything on one patient when resources are needed to help many others, all of whom have a higher chance of survival. Sometimes the many is more important than the one. But, as in most cases on this show, the ends of finding bone marrow matches, justifies the means.
In a third storyline, Halstead brings in an patient who is a heroin addict from a safe injection. The patient needs a heart valve replacement. The patient has already had two heart valve replacements and both have become infected from his continued drug use. Latham refuses to approve one more surgery given the cost, resources, and likelihood that the patient would do the same thing again. Halstead says the patient (whom he does not know) can get clean and asks Charles to evaluate the patient. Charles said the patient’s desperation to live makes it impossible to make a psychiatric diagnosis. Halstead begs him to basically make something up. Halstead writes a scrip for antidepressants and says that Charles told him to put in the order (Charles did no such thing). Halstead is lying and when he finds out, Charles calls him out on it saying he has lost all perspective based on his losing a previous addicted patient. After surgery, Charles finds the patient’s girlfriend passing him heroin. In this case, lying to one’s peers and in the medical record is both unethical and probably illegal. Halstead’s desire to make amends overrides any professional judgement, violating protocol, and just pushing the can of the consequences of the patient’s actions down the line.