On ‘Scrubs,’ a few more tests and some bedside reality are needed
“Scrubs”
ABC, Episode: “Our New Girl-Bro”
9 p.m. Jan. 1
The premise
Dr. Elliot Reid (Sarah Chalke) is pregnant and experiencing morning sickness, cravings and mood swings while working at Sacred Heart Hospital. In this episode, medical student Lucy Bennett (Kerry Bishé) assists her in taking care of a patient admitted with breathing problems who has developed a low blood platelet count.
Elliot believes that the low level of platelets (small cells that help clotting) are due to the blood-thinning drug heparin that the patient has been taking. She stops the heparin, then sends the patient almost immediately for a bronchoscopy, in which a tube is put into the bronchi, or passages to the lungs. Elliot explains to the patient that she will be put to sleep, that the procedure will last an hour and that she will be in a little discomfort afterward. Elliot also reassures the patient that she’ll visit later.
The patient tolerates the bronchoscopy well, but it is Lucy who sits with her afterward, then complains that Elliot should have been there. Elliot replies that a doctor has to learn how to take care of herself first, then the world.
The medical questions
Could heparin cause the platelet count to drop? If so, how long would a doctor have to wait after stopping a patient’s heparin before performing an invasive test such as a bronchoscopy, in which a tissue biopsy may be taken? (A biopsy could cause excessive bleeding if the platelets don’t clot properly.) Would a bronchoscopy be a routine test to evaluate breathing problems? Is general anesthesia used, and does the procedure last for an hour? Is it a risky procedure? Is it important for the primary-care doctor to check on the patient right afterward?
The reality
Heparin could cause a temporary decrease in platelets, but usually not to a level that would pose a bleeding risk during a procedure such as a bronchoscopy, says Dr. James L. Zehnder, professor of pathology and hematology at Stanford University School of Medicine. If the platelet count were only slightly low, a bronchoscopy could be performed after the heparin wore off (in about six hours).
If the patient had taken heparin a week or so earlier and the platelet count was still low, a doctor should consider heparin-induced thrombocytopenia, Zehnder says. This autoimmune response often leads to blood clots and, in the case of shortness of breath, calls for a CT scan, rather than a bronchoscopy, to rule out a pulmonary embolus.
Bronchoscopy would generally be done only if the platelet count was high enough (above 50,000 per milliliter) so that excess bleeding was unlikely, and a biopsy would probably not be taken unless the count was closer to 100,000, says Dr. Shawn Skerrett, professor of pulmonary and critical care medicine at the University of Washington.
The rush to bronchoscopy seems absurd in the case of this poor patient. Bronchoscopy is a diagnostic procedure that would be performed only if blood and sputum tests, X-rays, CT scan and breathing tests all failed to yield a diagnosis, says Dr. Frank Adams, pulmonologist at New York University Langone Medical Center and author of “The Asthma Sourcebook.” Usually it’s meant to detect a potential lesion, obstruction, unusual infection or inflammatory lung disease such as sarcoidosis. “It is far from a routine test,” Adams says.
A bronchoscopy is performed with intravenous sedation, meaning patients usually remain conscious but are very calm, not general anesthesia. And it is usually well tolerated, requiring 30 to 60 minutes, as the show suggests. The bronchoscope is usually in the airway for 15 minutes or so, says Skerrett. The patient is watched by a nurse afterward, and though the pulmonologist would be expected to check on the patient, it is not “necessary or customary” for a primary-care doctor like Elliot to do so, Skerrett adds.
There is also a pecking order crucial to the function of the hospital that is being violated here.
“I can’t imagine a medical student questioning an attending [physician] about this,” says Skerrett.
Not in the real world, that is.
Siegel is an associate professor at New York University’s School of Medicine and author of the e-book “Swine Flu: The New Pandemic.”
