“Grey’s Anatomy” “Freedom” episode ABC, May 22 (two-hour season finale)
The premise: Andrew Langston, 19, is hanging out with friends at a construction site. Trying to impress his friend Lola with his daring, he lies in wet cement. As it begins to dry into concrete, he is trapped. By the time he can be transported to Seattle Grace Hospital, almost four hours have passed.
The surgical team begins to bang off the drying cement piece by piece, giving Andrew intravenous fluids, calcium, glucose and insulin. The doctors believe that the cement is leaching water from his body while exposing him to alkali, which burns the skin; that toxic chemicals released from the cement are being absorbed; and that the concrete formation is causing a compartment syndrome (compression of nerve, blood vessels and muscle within a closed space, leading to impaired blood flow, and muscle and nerve damage).
The doctors put acetic acid (vinegar) on Andrew’s skin to try to counteract the effect of the alkali, and they perform a fasciotomy of his leg (cutting the connective tissue to relieve the compression on the muscle). But when they remove the last piece of hardening cement from his belly, Andrew goes into shock. The doctors think it is from toxins, but Dr. Cristina Yang (Sandra Oh) discovers that his low blood pressure and unstable conditions are caused by a clot in his pulmonary artery.
The medical questions: Does cement leach water and electrolytes from the body while causing alkali burns to the skin? Can the effects be neutralized with vinegar? Are the chemicals in cement life-threatening, and will they be absorbed by the body? Can being encased in cement lead to compartment syndrome? Can this immobility lead to a blood clot in the lungs?
The reality: Cement can cause alkali skin burns. When water or moisture is added to cement, calcium hydroxide is formed; it has a pH of 12 to 13, much higher than that of skin (pH 5.5). But though vinegar would neutralize the pH, “this is not generally done because the heat generated would cause more burns,” says Dr. Ben Honigman, head of emergency medicine at the University of Colorado School of Medicine. “The best neutralizer is copious irrigation with water.”
Drying cement and concrete can draw water from the skin, which can cause mild dehydration, but “it would be unlikely to cause electrolyte abnormalities,” says Dr. Edward J. Newton, chairman of the emergency medicine department at USC’s Keck School of Medicine.
Although cement does contain chemicals, including hexavalent chromium, that can cause skin irritation and allergic dermatitis, they are not absorbed in large quantities and the notion that a patient might go into shock from them is simply TV drama.
Insulin, glucose and calcium might be administered to counteract rising potassium levels, which can occur from muscle breakdown and resultant kidney failure, but wouldn’t be needed within four to six hours and would not be given without checking for high potassium.
Compartment syndrome from a high degree of constriction is not likely from the compression in this case because compression isn’t worsening. If the patient were still encased in cement long enough to cause deep burns, a fasciotomy might have to be done to relieve fluid buildup in the muscle. The use of a manometric measurement device to show that the pressure in the leg compartment is reaching a critical point is an excellent bit of medical detail.
Finally, immobility and compression could lead to urinary retention and damage the kidneys, or cause a clot to form in the leg and break off and travel to the lungs, but probably not in such a short time period. If there is shock and circulatory collapse from concrete encasement, it would likely be from internal bleeding, says Dr. Mark Morocco, an emergency medicine doctor at UCLA.
Dr. Marc Siegel is an internist and an associate professor of medicine at New York University’s School of Medicine. In the Unreal World, he explains the medical facts behind the media fiction.