‘Nurse Jackie’s’ ER missteps

“Nurse Jackie”

Showtime, 10 p.m. May 3

Episode: “Silly String”

The premise: Nurse Jackie Peyton ( Edie Falco) is at home with her family and friend Dr. Eleanor O’Hara (Eve Best). Jackie’s daughter Fiona (Mackenzie Aladjem) is playing with a fake arm cast when she cuts her lip, requiring stitches. O’Hara agrees to use Jackie’s emergency kit (without gloves) to sew up Fiona’s lip even though Fiona’s father, Kevin Peyton (Dominic Fumusa), protests that she should be taken to All Saints Hospital for the procedure.

At the hospital, Libby Sussman (Barbara Barrie), an elderly and important donor, is brought into the emergency room, having blacked out at an auction. She is awake and alert and seems fine. Jackie draws her blood, and Dr. Fitch Cooper (Peter Facinelli) orders an EKG and chest X-ray. They believe the blackout was due to a vaso-vagal episode, a benign event in which the blood pressure and heart rate drop because of excess stimulation of the vagus nerve.

Later, however, Sussman blacks out again and goes into cardiac arrest. CPR is started, but she doesn’t respond and dies.

Also in the episode, O’Hara’s lover, Sarah Khouri ( Julia Ormond), is suffering from a large necrotic area on her arm after being bitten two weeks earlier by a brown recluse spider in Arizona. At the hospital, Jackie brings her into the bathroom and gives her two injections of the antibiotic Augmentin in the buttocks to treat it.

The medical questions: What is the risk of infection or other complications if sutures are applied to a laceration without proper sterile technique in a non-medical setting? What is the proper medical work-up for a patient who is brought into the hospital after apparently fainting? Is there a way to differentiate between a benign faint and a life-threatening blackout? Are brown recluse spider bites common in Arizona and do they cause nasty wounds filled with dead (necrotic) tissue? Is the proper treatment antibiotic injections?

The reality: For simple, uncontaminated cuts like the lip laceration portrayed on the show, the risk of introducing infection from suturing would be small if both the doctor’s hands and the wound were washed well with tap water, says Dr. Mark Morocco, associate emergency-residency program director at UCLA. In fact, studies show no difference in infection rates when comparing sterile water with tap water, and non-sterile gloves with sterile gloves, Morocco says.

Even a doctor sewing with her bare hands, provided they were washed well, would not add to the infection rate, adds Dr. Edward Newton, chairman of the department of emergency medicine at the Keck School of Medicine of USC. The rich blood supply of the lip clears away bacteria rapidly, and the wound would be unlikely to become infected. Despite this, the hospital setting is still preferable because of the ability to irrigate the wound under high pressure, which further decreases the risk of infection, says Dr. Benjamin Honigman, chairman of the department of emergency medicine at the University of Colorado School of Medicine.

And Morocco adds that the better lighting in a hospital ER would help the doctor in lining up the vermillion “red” edge of the lip with the skin.

Three percent of emergency room visits are for syncope (faints). Honigman and Morocco agree that an EKG and blood tests (looking for anemia and electrolyte disturbances or heart damage) are appropriate first steps. But Morocco points out that a careful history and physical examination will make the diagnosis in the vast majority of cases, and a patient’s advanced age should make a doctor more concerned about a possible heart problem.

“Life-threatening blackouts are usually sudden in onset,” Honigman says, whereas faints are associated with lightheadedness and feeling faint. Morocco believes that the doctors should have been on the lookout for a cardiac arrhythmia (irregular heartbeat) and should have admitted a patient like Sussman to the hospital to monitor her more closely, just in case she had a heart problem, rather than keeping her in the ER.

As for brown recluse spiders, bites have been reported in Arizona, but entomologists believe the wounds are actually from the much less venomous desert recluse spiders (the brown recluse is predominantly found in the Southeast). The bite might still be necrotic, though smaller than depicted, but would generally respond to direct treatment of the wound, as would the larger, more craterous brown recluse bite.

Many doctors treat these spider bites with antibiotics, though there is no evidence that antibiotic use improves outcome, says Newton. Oral antibiotics would be sufficient — and as Morocco points out, Augmentin is actually an oral antibiotic.

Given the shoddy care in the All Saints Hospital ER, perhaps it isn’t surprising that Libby Sussman decides to withdraw $1 million in funding before she dies.

Siegel is an associate professor at New York University’s School of Medicine.

marc@doctorsiegel.com