Posted on October 14, 2019 at 1:23 AM
by Craig Klugman, Ph.D.
The Good Doctor (Season 3; Episode 3): Informing a resistant parent; The Resident (Season 3; Episode 3): The Creepy Dr. Cain; New Amsterdam (Season 2; Episode 3): We don’t pay for the right things; The lack of adequate FDA testing of medical devices; Chicago Med (Season 5; Episode 4): Assault, Choosing cryonics, abuse of power; Grey’s Anatomy (Season 16; Episode 3): Mistaken identity and withdrawal decisions
Michelle Reynolds is a 14-year-old girl who comes in with abdominal pain—looks like a gallbladder issue. She has intense leg pain that turns out to be part of a clot breaking off. The clot is caused by her birth control pills, a prescription she admits to taking after having lied about it earlier. During a procedure to put in a femoral stent, Brown sees that the patient has incisions on her leg that look like she is cutting. We learn that her mother has brought in 3 foster children to the home and the patient is expected to take care of them. Brown suggests to the mother that Michelle speak with a psychiatrist, who tells Brown, definitely no. Brown suggests therapy to the patient, who says yes. When mom complains to Lim, Lim offers the defense that Brown was concerned that Michelle would harm herself, in which case the consult was required. But, Lim continues, Brown should have informed the mother.
Underlying this case is that Brown is to do conduct her first solo surgery on Michelle. When Brown admits to Lim that she’s scared, Lim tells her never to say that again. Lim explains that as women of color, they have to be twice as good as everyone else and thus can’t afford to be admit fear. After not informing the mother of the psych consult, Brown is removed from the surgery. When mom sees how much Brown cares for her patient, Melendez convinces her to let Brown do the surgery. And in recovery, the mom asks for the therapist’s card.
Nevins questions Dr. Cain when he walks out of a delicate surgery if he always leaves his resident alone when doing surgery. He responds that his residents are “second to none” and “rarely make mistakes” and “that all is well.” He clearly does not like being questioned. In another case, Nevins stops a surgery Cain is about to do because the patient has myasthenia gravis and can be treated with medication. Cain tells Nevins that she cost him and the hospital $150,000 for the cost of a surgery that was not done. He then admits to her that he does surgeries for revenue, not for the patient’s benefit.
Two ethical issues in these brief scenes. Patients should only undergo surgery when it is necessary and for their benefit, only. When patients are viewed as ATMs, then we objectify them and lose the most basic principles of medicine—to always act in care of the sick and never for one’s own gain (only). The second issue about residents operating without direct supervision is trickier. We do not know what year or how experienced the resident is, whether the resident has performed this procedure before or even whether Cain was leaving the OR to talk to Cain and then heading right back in.
In a second storyline, a cop comes into the ED with an injured (impaled on rebar) serial house burglar. The criminal is part of a group that has kidnapped a middle-aged man from his house. In the end, Conrad takes it in his own hands to get the criminal/patient to tell where the kidnap victim is by torturing the patient. He says, “Greatest good for the greatest number” meaning he is willing to injure a patient to save a victim’s life. Pravesh says that he wants no part of it and will not help. However, he also does not report Conrad. At the end, Conrad is watching the news which reports that the kidnapping victim was saved. Let’s get this straight, it is never acceptable to use medical knowledge to purposefully harm a patient. While we are not shown the torture, we must assume that it took place. Such actions are a violation of nonmaleficence. I suspect we will see repercussions from these actions in future episodes because the ends do not justify the means.
Amsterdam (Season 2; Episode 3): We don’t pay for the right things; The lack of adequate FDA testing of medical devices
Reynolds has a senior patient who has reopened her leg wound (a blood vessel was harvested for her heart surgery) after she fell and no one found her for 14 hours. While Medicare will cover the repair, they won’t cover a home health aide to check in on her and prevent the patient from needing to return. This storyline calls attention to the odd reality of American health care that we pay for procedures but not for care (or for preventive care). In the storyline, Max’s new assistant, Tod Benson, comes up with a simple solution—adopt a dog for the woman and pay for a dogwalker. That way, someone will check on her twice a day—when picking up the dog and dropping it off.
Another patient comes in and is diagnosed with cobalt poisoning. The cobalt is from a defective hip replacement, which the FDA pulled from the market (metal on metal hips) and the manufacturer claims to have fixed. The patient wants to know who will pay for the surgery? Who will pay for the 8 weeks of work that he has to miss and rehab? Sharpe says that the manufacturer will pay for it all. In a later scene, Sharpe and the patient are in a board room across from lawyers and executives from the manufacturer. The company does offer to cover all of the costs. But now, Sharpe wants more. To get around the FDA ban, the company simply put a coating on their artificial hips so she wants her patient (and any of their patients who come through the door with the same problem) to receive the more expensive ceramic hip. We learn that the only reason the company even showed up is because of her status as a television doctor. The company tells her that if she goes on television and bad mouths the company then they will bury her in lawsuits. She goes on TV news and tells her story, but after receiving a text from Max telling her that the company caved, she changes her tune and blames the FDA. A medical device does not have to be tested if the manufacturer can show that it is substantially similar to an existing product on the market. Technically these companies are in FDA compliance, so the problem is that the regulations, testing, and oversight are inadequate to protect patients.
Shep is an 18-year-old male who comes to the ED. He has terminal glioblastoma (brain cancer) and makes Choi wait while he finishes a phone call. The call was to a cryonics company (which will “vitrify” him) that is on their way. While talking, he drinks from a coffee mug—a cocktail of drugs to kill him. Shep declares that he has a DNR and a DNI and that he refuses all treatment. Choi immediately calls for a nurse to come in and pump his stomach, which Lockwood stops. In a staff meeting, the hospital attorney says that given his terminal condition, whether Shep can be allowed to kill himself is a grey area. Neurosurgery verifies the condition is terminal. The attorney says that the patient has a right to refuse treatment and paternalistic Choi says that he’s a kid and he doesn’t understand. The lawyer says that unless the patient lacks decisional capacity, they have to follow his wishes. [Where is the ethics consult in this?] Charles volunteers to speak with Shep who explains, “If the hospital across the street could cure me, would you feel ethically compelled to send me?…That’s what I’m doing, sending myself to a better hospital, only the hospital I’m going to is in the future.” Charles asks if Shep understands that he’s trading his last year of life for the unknown. He does. Later, Choi tells Charles that Shep is committing suicide and needs to be put on a psych hold. Charles explains that Shep is “remarkably clear-headed” and views this act as saving himself. His parents want to do everything to save him. Charles then leads the parents to say that Shep has acted rashly since his diagnosis at which point Charles declares the patient incompetent and treatment begins (ventilator, dialysis). Shep keeps going into heart failure and Choi keeps shocking him. Later, the parents decide to honor their son’s wishes and have Choi withdraw support. The vitrification team gets immediately to work. In this storyline, the conversations on the law and ethics are accurate. The violation of ethics comes when Charles tells the parents what to tell him for him to declare Shep incompetent, even though Charles had found the patient to be quite rational.
Meanwhile, Charles is also trying to prevent his wife from having surgery to repair her broken arm. Given her advanced cancer and chemo regimen that has suppressed her immune system, surgery is risky. She claims that he is controlling her by telling his colleagues not to let her have the surgery. In fact, he did this. Charles is being paternalistic and making decisions for his competent wife—using his professional position to force a family member to follow his wishes. This is a gross violation of autonomy and of professionalism. In the end, she chooses against surgery.
A woman walks into the ED carrying a bloody newborn that is whisked to the NICU. The woman has a cut hand and has lost much blood, but is refusing care. Sexton wonders whether the woman is the mother or if something more nefarious is going on; she wants to draw some blood to check for levels of pregnancy hormones. Marcell stops her, “You draw anyone’s blood without consent; that’s considered assault…I like being a doctor. I’m not going to jail.” Sexton said without his help, she’d call DCFS because the cut is on the wrong hand for things to have happened as she claimed. While DCFS arrives, Marcell has given the woman an anti-anxiety medication that put her to sleep (with no admission and no record, that means he’s treating her without an exam and without keeping records). In a later scene, a woman is brought to the ED unconscious with her abdomen cut open—her baby had been cut out of her womb. The birth mother is saved and the woman who cut her is arrested (we are told she probably had a mental break after losing her son to leukemia recently). In one of the final scenes, we learn that Marcell knocked out the perpetrator and then drew her blood to run labs. He assaulted the woman. A prisoner, a criminal, and people suspected of a crime retain their right to refuse treatment and doing testing on them without their consent is a violation of their rights. Marcell is praised as a hero, but he should be reported. Sexton demonstrates that health care providers are required reporters—if they suspect abuse or endangerment of a child, then at least in Illinois, they are required to report; no evidence is needed.
Heather is a woman who has fallen 30 stories and is brain dead. Her skull is fractured and her face badly damaged. Her two sisters do not know what their sister would have wanted and disagree—one wants to withdraw support and the other wants to maintain support. The three have been estranged. After the two sisters have argued for hours, Weber tells them that they have to get it together and make decisions. One feels that Heather would not want to live on machines; the other thinks Heather was young and doesn’t want her to die. Weber says if they can make the decision together, then maybe their sister’s death would bring them back together. After withdrawing support, the phone rings and it is Heather—someone stole her bag. They just withdrew support on their sister’s mugger. This case was presented as a minidrama, taking on a typical scenario (family disagreement about end-of-life choices) and brought them together. The twist is pure drama and although it won’t be revisited in the future, would require a root cause analysis, risk management investigation, and bringing in the police (since the patient was accused of a crime). This case is based on a real one, where a woman thought she was removing life support from her brother, but it turned out to be someone else (similar name). The woman sued for emotional suffering (a joke is made in the episode that Weber is being nice so they won’t sue) and the identity of the real patient was never found.
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