Methods might cause 'Royal Pains'

"Royal Pains"

USA Network, July 30

Episode: "The Honeymoon's Over"

The premise

Chuck Sutherland, a famous children's book illustrator, has been admitted to Hamptons Heritage, a hospital on Long Island, for hypertrophic cardiomyopathy and a cardiac arrhythmia (in this case, atrial fibrillation, in which the collecting chambers of the heart quiver instead of pump). He is supposed to have surgery but, instead, signs out of the hospital "against medical advice" with prescriptions for the diuretic Lasix, which reduces blood volume, and a calcium channel blocker, which lowers blood pressure and heart rate.

Dr. Hank Lawson (Mark Feuerstein), founder of HankMed, a comprehensive concierge doctor's service, meets Chuck in the lobby of the hospital, accompanies him home and assumes his care. When Chuck stops his calcium channel blocker ("it makes me feel like crap") and increases his Lasix, Dr. Hank determines, correctly, that he is dehydrated and ototoxic (hearing damaged). When Chuck becomes unconscious and begins foaming blood from the mouth, Dr. Hank determines, again correctly, that he is in pulmonary edema (severe heart failure) and treats him with oxygen and positive airway pressure, and Chuck improves. When he passes out again with a very low heart rate, Dr. Hank discovers that Chuck has just drawn a yellow illustration, and decides that his problem is now due to digitalis toxicity from drinking foxglove tea (from which digitalis is derived). Dr. Hank points out that digitalis toxicity causes a patient to see yellow and experience heart block. He administers an injection of the anti-arrhythmic drug Lidocaine; Chuck improves and is finally taken back to the hospital.

Hank's wild diagnostic stabs in the dark seem to have turned out to be accurate, at least this time.

The medical questions

What is hypertrophic cardiomyopathy, and how is it usually treated? Can atrial fibrillation be treated with calcium channel blockers? Could a patient who stops such drugs and increases his diuretics become dehydrated, with his hearing affected, and could he then develop severe heart failure? Would he be treated with oxygen and positive airway pressure? Could he slow his rapid heart rate by drinking foxglove tea, and would it lead to digitalis toxicity? If so, would the condition this be treated by Lidocaine? Would a doctor be allowed to take over the outpatient treatment of a heart patient in such a reckless manner without jeopardizing his medical license?

The reality

Hypertrophic cardiomyopathy is a condition, usually genetic, in which parts of the heart muscle become abnormally thick. It is only rarely treated surgically, says Dr. Andrew Goldfarb, a cardiologist at North Shore University Hospital (a real hospital on Long Island), and then only when it is causing an obstruction so severe that the symptoms cannot be effectively treated by medication alone. Calcium channel blockers can, indeed, be used to slow the heart rate in patients who develop rapid atrial fibrillation; they also relax the stiff heart wall of hypertrophic cardiomyopathy.

An excess of diuretics, which can sometimes be toxic to hearing, would be especially problematic in patients with hypertrophic cardiomyopathy because a decreased volume of blood in the heart can make the obstruction more prominent. At the same time, stopping the calcium channel blocker could cause the heartbeat to return to a rapid rate. The severe heart failure that can result could be treated initially with oxygen and positive airway pressure, though it is unlikely that the response would be as dramatic as the show depicts.

Digitalis toxicity can occur from drinking foxglove tea; the drug is derived from the herb. But a patient with atrial fibrillation who deliberately treats himself with foxglove to slow his own heart rate would find it impossible to regulate and, therefore, dangerous. Such a patient, however, may see everything with a yellow tint (though it is unlikely that he would draw in yellow).

But the entire premise that Dr. Hank can make one satisfactory diagnosis after another and institute emergency treatment without resorting to confirmatory laboratory testing or immediate hospitalization "hearkens back to an era of primitive medical care, when foxglove was the only available treatment for heart failure," says Dr. Fred Weinbaum, chief medical officer at Southampton Hospital, the hospital on which the show is modeled.

Weinbaum says that Dr. Hank's preemptive treatment is "foolhardy and dangerous given the potential for error."

As for the Lidocaine, it could be used to treat a ventricular tachycardia (abnormal, fast rhythm originating from the ventricle) that can result from digitalis toxicity, Goldfarb says, but it would more likely lead to a very slow heartbeat, causing Chuck to pass out. This would not respond to Lidocaine but to atropine, potassium or a temporary pacemaker. Administering Lidocaine blindly in this case would be reckless care. Further, patients who have taken too much digitalis often need a blocking antibody (Digibind) in the hospital to help remove it.

Finally, although a doctor could treat such a noncompliant patient without jeopardizing his medical license, his reckless treatments could easily lead him to injure or kill a patient, especially if the treatments fail. Luckily for Hank, Chuck recovers. Weinbaum concludes, rather wryly, that Hank's impulsive shenanigans are the "stuff of comedy, not serious medical drama."


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

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