Memo to president: Find another doc

“Commander in Chief,” ABC, May 31

The premise

PRESIDENT Mackenzie Allen (Geena Davis) wakes up feeling feverish. She vomits, but still manages to summon the energy to board Air Force One. When she develops abdominal pain, the White House internist diagnoses acute appendicitis and possible rupture -- after simply eliciting severe right lower quadrant abdominal tenderness by palpating her flank. He states she has sepsis (a life-threatening systemic infection) and insists the plane be landed immediately for emergency surgery. At the hospital, the top general surgeon attempts to remove the appendix laparoscopically. But finding a perforated appendix, and with her blood pressure dropping, he switches to an open procedure. The president survives and a day later resumes her duties -- without a full course of intravenous antibiotics or bowel rest.

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The medical questions

WOULD the victim of acute appendicitis be likely to decide to board a plane? Is the diagnosis as apparent as the White House physician maintains? Is he correct to urge emergency landing and surgery? Can a perforated appendix be diagnosed before a laparoscopic procedure is attempted? After the surgery is successful, can a patient recovering from peritonitis (an infected lining of the abdominal cavity) return to work this quickly?

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The reality

DAVIS’ convincing portrayal of a president developing appendicitis is partly wasted by a constellation of inaccurate facts regarding the disease. The initial symptoms are debilitating enough that it is very unlikely that a person thus afflicted would ever decide to board a plane, even a president carrying out her duties on Air Force One.

Further, a physician is unlikely to be as sure of the diagnosis, as the White House physician is based only on his exam without further tests. In fact, a doctor cannot always be completely sure of this diagnosis until surgery. Other real possibilities include viral or bacterial gastroenteritis, diverticulitis, colitis, inflammatory bowel disease, ectopic pregnancy or ruptured ovarian cyst.

The demand that the plane be landed at once is certainly dramatic, but the president does not show signs of sepsis. She remains awake and alert, is not breathing rapidly and does not appear to be turning the ashen color one would expect with an unstable patient who, as sepsis develops, would have falling blood pressure.

Once on the ground, she would almost certainly receive a confirmatory CT scan. It could be done in minutes and might show the perforation -- making an open operation mandatory and saving the time wasted with the laparoscope.

Finally, after such a bad case leading to peritonitis, it is inconceivable that any patient, especially a president, would be back up in days. Intravenous antibiotics and bowel rest with a very gradual progression back to a normal diet would be standard care. A president could govern from the bedside, but not from the oval office.

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Dr. Marc Siegel is an internist and an associate professor of medicine at New York University’s School of Medicine. He is also the author of “False Alarm: The Truth About the Epidemic of Fear” and “Bird Flu: Everything You Need to Know About the Next Pandemic.” In the Unreal World, he explains the medical facts behind the media fiction.