Posted on December 11, 2018 at 7:43 PM
by Craig Klugman, PhD
This episode revolves around an unidentified pathogen invading the ED when two patients are brought in immediately after their flight from Malaysia lands. Both of them die and the ED is quarantined: All ambulances are diverted and walk-ins are sent away. Rather than panicking people, their coming and going from the ED is slowed down or delayed. Once Tyler— the EMT who brought in the patients—becomes sicker, Lim lets everyone know that they are on lock down and no one is leaving. When one person picks up a chair to break a window and escape, Lim sedates him. Lim contracts the infection and Tyler dies, leaving an ED full of nervous people and only two residents, two nurses, and a security guard to deal with them.
In reality, this is close to how such a situation would be handled: Assess what is going on, take precautions, contact state and federal officials, avoid panic, initiate quarantine. What is not seen is the effort to contact everyone on the plane and the airport in order to quarantine them as well. The CDC does not appear, and we are told that is because an epidemiologist is in Malaysia dealing with the disease (if a hot zone has been identified, why is there a flight leaving/arriving without screening passengers for symptoms, especially when the incubation period is a matter of hours (and fewer hours than the long flight)?) and others on the East Coast are stuck in a snow storm (I suppose that despite several schools of public health in California, two major medical schools up the road, and a CDC office in Los Angeles, no one else is available?). All hospitals have protocols for how to deal with disasters and pandemics. This would often be the first place that a hospital would go to determine its operational steps. In this case, however, it seems to be the hospital president and the board that are making the decisions without reference to their plan, their ID experts, or even local public health officials. I have worked with several jurisdictions and one hospital in creating their plans and none of them placed decision-making with the hospital board. Most large urban hospitals also have infectious disease units and communicable disease consult services: These should have been consulted (and if this hospital for some reason lacks those, there are other hospitals nearby that do have this expertise—Stanford and USCF are not that far). Given that the ED still had communications, there should have been a greater use of telehealth.
The other element not explored in this show is employing people who are well (or visiting) to help those who are sicker. Although not trained health care providers, these civilians can help distribute food, hold hands, and help out as directed. Given the limited resources in this setting, using able-bodied folks who can help is essential. In addition, giving people tasks to do helps prevent panic.
In a second storyline, a man in his mid-20s is having chemo and full body radiation to treat his leukemia. His biological father is lined up for a bone marrow transfusion. The patient complains of back and arm pain which Melendez determines is a heart attack caused by blocked white blood cells. He thinks moving up the treatment will take care of the problem. After irradiating him the team needs to perform the transplant but the donor is stuck in quarantine. The patient has pneumonia and the antibiotics are not working. He asks to sign a DNR and in a few hours dies. However, Melendez ignores the DNR order.
Brown says, “He signed a DNR.”
Melendez, “He shouldn’t have.”
“This is battery” Brown states. (Perhaps after a season of assaulting patients this way she is beginning to show some growth?)
“He doesn’t need to die,” responds Melendez.
Though reluctant at first, Brown begins CPR while Melendez intubates (answer to the above question is no). The end of this story will appear on January 14 when this show has its Spring Premiere, but Brown is correct—the DNR order should be followed and to ignore it as a battery. Melendez is acting because he feels helpless to assist Lim (the episodes opens with them together in bed) and this patient is someone whom he thinks he can help instead. We also learn that the donor is stuck in the ED quarantine.
A third story sees a patient in the ED needing surgery to repair a bowel obstruction. However, since the ED is under quarantine, a non-surgical approach is needed. An enema seems to alleviate the problem but the problem only returns again. The team constructs a makeshift OR and with Lim’s verbal guidance (she is under separate quarantine for showing symptoms), prepares for a “combat style” surgery (who is doing the anesthesia though?). They discover necrotic bowel and a perforation. When Murphy is called away to help another patient, Reznick finds herself over her head dealing with a bleed when Lim collapses and cannot give her further direction on the surgery. Again, given the fact that they are in a hospital with electricity and communication, it is not clear why a non-quarantined surgeon was not guiding the operation (we see there are even cameras watching what is going on) except to create more drama.
The episode ends with no resolution to any storyline as this is the “fall finale.” Presumably the story will pick up in the new year and resolve these issues. While we leave this show for the next month, I have been thinking about how each of these characters seem to embody a different ethical theory. This approach is unusual since on many medical shows, the focus is on utilitarian perspectives—what is ‘ethical” is what leads to the best outcome. Brown represents an ethics of care framework—she is all about empathy and also willing to lie and manipulate the system to get what she feels is best for her patients. Reznick is the objectivist as she focuses more on what is best for advancing her career and thus can come across as less than compassionate. Her approach is transactional and thus represents the person who is willing to do the right thing, when it benefits her; she is always competing against others. Park seems to represent social contract ethics. As a former cop he has a strong notion of right and wrong and understands his role in the social order. He is also willing to lie to patients (as we saw last week) in order to keep the peace. Melendez is usually a virtue ethicist as he is a person of good character who makes good choices out of habit and is a role model for other residents. Lim represents principlism as she seems to try to balance patient autonomy and beneficence, but will also violate it to avoid harm (nonmaleficence). She also demonstrates a sense of justice when she sedates the man in the waiting room (a violation of autonomy) to protect the greater group. Murphy, with his autism, represents deontology—following the rules. This was demonstrated in last week’s episode where he found driving a challenge because other drivers do not follow the rules exactly. He will speak out without regards to the best way to approach a patient simply because what he offers them is the “right” way to approach a decision. Under the Kantian version there is no room for compromise, which is where Murphy often starts, but by the end of each episode he finds a way to resolve conflicting prima facie duties through a more nuanced form of deontology.
A “burglar” is brought to the ED after being stabbed by a home owner—a middle-aged female. However, we quickly learn that the burglar is actually her husband of 29 years. The woman (who is a physicist) says that the man she stabbed looks like her husband but he is not her husband, he’s “an imposter”. A month ago she was diagnosed with a pituitary adenoma. One of the drugs she is taking to keep the tumor from growing can cause Imposter Syndrome as a rare side effect. Charles gives her an anti-psychotic to reverse the side effect, but that drug causes a severe and violent reaction. Before sedating the patient, she tells Charles that she wants the tumor removed even knowing that her doctors said it was inoperable. She says that being able to love her husband is the most important thing. However, the husband says no, that he will not allow her to make this risky choice until he hears it from his wife. However, without the anti-psychotic, his wife will not recognize him. Charles tells him, “Legally, it’s not your decision to make.” The husband tells Charles and Goodwin that he has already spoken to his lawyer. By the elevator Charles tells Goodwin that he cannot unhear the patient’s request. Goodwin asks him if he can be 100% certain that the patient had full decisional capacity. Charles says he understands the husband’s perspective but he is “legally and morally bound to honor her wishes.” Goodwin states that with the threat of a lawsuit, the hospital won’t allow the surgery without the husband’s consent. When the patient awakens, she is back to viewing her husband as an imposter.
A patient has the legal and ethical right to make their own medical choices if they are competent and capacitated. In this case, Charles is correct—given his experience and long history in doing capacity determinations—he knows that the patient was able to give consent. However, given that she had just stabbed her husband whom she did not recognize and her tumor, it would be hard to believe the patient could make any decisions. Unfortunately, there were no witnesses to the patient’s statement, thus no way to document the patient’s state of mind or what she said. Goodwin is thus also correct: On the surface, the patient may not have been capacitated, a state that would require the husband’s consent. Charles is following his legal and medical requirements. Goodwin is taking a CYA stance. This delicate balance is the condition of the modern medical system a balance between medical ethics, health law, and an administrative class that is more concerned with avoiding exposure and maximizing profits than in patient outcomes (they are concerned about patient satisfaction and ratings, but not outcomes—unless bad outcomes comes with a financial penalty).
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