by Craig Klugman, Ph.D.
The Resident (Season 3; Episode 6): Gambling on patients and dangerous surgeries; New Amsterdam (Season 2; Episode 8): Unrelieved pain; Making promises; Chicago Med (Season 5; Episode 8): Assent/Consent, Medical decision-making by internet vote, not treating family, creating a public health threat
During a high stakes game of poker, Cain wins a chronic spinal patient in a poker game. Cain wants to perform an experimental surgery on the patient to replace four spinal discs with artificial ones. The surgery has never been done in the U.S. but has been done a few times overseas (we are not told where). In a side effect of the surgery, the patient’s throat closes off and Voss needs to take him to surgery as his life is in danger. Turns out the artificial discs broke—the more discs used, the greater the likelihood of this happening. Cain is mad that Voss took his patient back into surgery (mainly because she will get credit for the billing and not him) but she attempts to reach détente with him.
In reality, patients are people and should not be gambled. They should receive the best care from their doctors. Also, it is not clear that the patient was told how experimental this procedure was. We do not see the consent conversation but my guess is that it was weighted toward the benefits.
Sharpe’s patient has a rare form of cancer and is in extreme pain. Her prescription runs out before she can get a refill because she needs to take multiple times the standard dose. In search of relief, she has sought out heroin which provides temporary relief from her pain. Sharpe wants to help her medically, but the patient is addicted now. The patient walks out of the hospital and goes to a drug den. Sharpe finds the patient there and brings her to a safe injection site (illegal, but supervised and safe tools are provided—patients have to bring their own drug). Sharpe is arrested by the police after she is photographed by a sting operation going into the safe den space. The chair of the board bails her out, but begins an inquiry (more to come in future episodes)
In reality, the opioid epidemic has created problems for people who struggle with pain. New regulations limit the doses a patient can have, the number of pills they can have, and how long until they can get a refill. These policies are attempts to prevent recreational use of the drugs. The unintended side effect is that people who live with pain are left without access to relief.
Ms. Alvarez comes to the hospital and is diagnosed with fetal demise. Duke, an arrogant student, tells the patient that they have the best doctors in the world and tells her that their doctors will save her baby. Reynolds says, “Never promise a patient that everything will be fine because you never know what might happen.” Duke asks, how do you give hope without telling them that things will be better, or promising them good outcomes. Reynolds explains the contradiction by saying that you should just be there for the patient. “Just be there”.
Chicago Med (Season 5; Episode 8): Assent/Consent, Medical decision-making by internet vote, not treating family, creating a public health threat
Laurie Shelton is a 16-year-old girl who collapsed on the job. She had a kidney transplant 6 weeks ago. Halstead suspects a blood clot and wants a CT with contrast. However, her parents say she is allergic (had a reaction last time). Halstead gives her heparin instead, which does not work. Laurie wants to use steroids to suppress the allergic reaction and have the scan. Halstead says that he needs her parent’s consent, even if she wants it. The risks are high (death) and she could live without a kidney, though not without discomfort and pain from her disease. The parents’ consent. They get the scan, but not before Laurie needs to be intubated. The clot is busted and the kidney is saved. This case is a classic risk/benefit analysis where the patient, a teenager, gives assent and has to convince her parents to be on board. Even with her desire and understanding, her parents need to consent.
Dennis is a livestreaming star who comes to the ED with stomach pain. He streams his life 24/7 (YourAreTheJudge.com) including his encounter with the medical system. Every decision he makes is voted on by his followers and he does what they say. When Choi asks him to take a seat for an exam, the voters say no, so Dennis stands. When Choi says he wants a CT scan, the voters agree to allow it. What would Choi and Dennis do if they had said no? The scan shows appendicitis and Dennis needs immediate surgery. A voting fan asks if there is an alternative to surgery and Dennis asks them to vote—surgery or heavy antibiotics. The votes show no surgery. Choi says this is not a way to make medical decisions, but Dennis follows his voters. Charles comes in after having checked out the patient’s website. Charles wanted to emphasize that opting out of surgery could kill him. Dennis explains that following the vote is a pact, he will never break it. Charles says that the patient understands the decision and he can leave the decision to others. He is capacitated. When Dennis’s appendix is about to burst, a voter suggest Cialis and Choi said they have no idea what they are talking about. His girlfriend announces they reached 1 million followers and their ad revenue will double. He’s sticking with the vote. To prove a point, Charles takes Dennis to the roof of the building and asks the followers whether Dennis should jump. They vote yes, he should jump. Dennis says, no, he won’t jump and his followers start fleeing. He then agrees to have the surgery, which goes well and he makes a full recovery.
When Noah Sexton is carried into the ED after having been beaten, Choi treats him. Goodwin removes him from being attending on the case because Choi is too close (he’s dating Nurse Sexton, Noah’s sister). Choi says he can separate his personal and professional, but Goodwin tells him no: He thinks he can, but he can’t. Although constantly violated on this show, the guideline is a good one.
Ben is Maggie’s cancer buddy and romantic partner. When he comes down with the measles and pneumonia, Manning explains his immunocompromise means the disease will attack his organs and he will die within days. The Chicago Department of Health announces a mandatory quarantine because of an outbreak, which means Ben is going to die in the hospital. Maggie wants Manning to change his chart to say he’s “post infectious” so that Ben can be released. Manning says that it is illegal and unethical. Instead, Maggie forges Manning’s signature so that she can take Ben home to die. Besides breaking the law, how many lives will Maggie endanger with her move—Ben will infect many people. When they get to Ben’s house, Maggie sees that the apartment building is filled with children. Ben tells her it is okay, and they should return to the hospital. Will Maggie be arrested? Will Manning report her? Did Ben infect others? We may never know, or next weeks’ episode may continue the story.