The Unreal World: Probing trauma procedures on ‘Miami Medical’
CBS, 10 p.m. Friday, April 9
Episode: “88 Seconds”
The premise: Kate Prentice (Erin Chambers) is a 23-year-old diabetic shot in the lower back by an ex-boyfriend. She is brought to the emergency room, losing blood and with her blood pressure having dropped to 70/40 despite the “wide open” administration of intravenous fluids. As Dr. Matthew Proctor (Jeremy Northam), chief of trauma surgery, probes the wound, Kate develops a potentially lethal heart arrhythmia (ventricular fibrillation); she’s shocked back out of it with a defibrillator.
Dr. Eva Zambrano (Lana Parilla) and Dr. Chris Deleo (Mike Vogel) both suspect that the pericardium (the sac around her heart) is filling with blood and constricting the heart, a condition known as cardiac tamponade. They want to crack open her chest to drain the pericardium of fluid and enable the heart to pump freely again, thereby raising her blood pressure. Instead, Proctor performs a sonogram of the heart, which shows no fluid. The doctors then conduct an exploratory abdominal surgery (laporotomy) and find that a kidney has been nicked by the bullet and is hemorrhaging.
They also discover a tumor in the adrenal gland atop the kidney. When Zambrano touches the kidney with a probe, Kate’s blood pressure and heart rate skyrocket. A CT scan shows that the tumor hasn’t spread and is likely not malignant. An MRI with contrast dye confirms the diagnosis of a pheochromocytoma, an adrenal tumor that makes excess amounts of hormones, including adrenaline.
Zambrano suggests treating the patient for 48 hours with beta and alpha blockers (blood pressure medications that will blunt the effects of the hormones) prior to removing the tumor, but Deleo points out that the patient’s kidney could rupture from the laceration that scans show extends all the way to the kidney hilum (where the main artery enters the kidney and the veins leave).
The doctors decide to operate, with Zambrano ordering that the blood pressure medications be administered for one hour before surgery. The adrenal veins are tied to prevent adrenaline from flowing back to the heart, and the tumor is removed, but then the kidney hemorrhages. When Kate’s blood pressure drops precipitously, Proctor decides that the entire organ must be removed.
The medical questions: Would trauma surgeons ever open a patient’s chest to drain the pericardium of fluid before confirming the diagnosis? Would an exploratory laporotomy be performed prior to a diagnostic CT scan? Would an MRI scan confirm the diagnosis of a pheochromocytoma? Should the damaged kidney be repaired or removed immediately rather than delayed for a further diagnostic workup? Could the tumor’s removal be delayed if the kidney bleeding is controlled?
The reality: Today’s trauma surgeons would almost never blindly open a patient’s chest unless the heart had stopped beating, says Dr. Gerard M. Doherty, head of general surgery at the University of Michigan, because sonograms are widely available and very effective at showing fluid around the heart.
But an exploratory laporotomy would be undertaken immediately, prior to a CT scan, he says, especially in an unstable patient.
As for using an MRI scan to confirm the presence of a pheochromocytoma, Dr. Pamela Hartzband, an endocrinologist at Harvard Medical School, confirms that it is indeed the test of choice. The patient could be tested for the hormones the tumor secretes (adrenaline and related stress hormones), Hartzband says, but the results would take a few days to become available; thus such tests wouldn’t be practical in an unstable patient. Intravenous blood pressure medications may be given during surgery to counter hormonal surges from the tumor, she says.
Doherty says that the removal of the adrenal tumor could possibly be deferred if the kidney bleeding could be stopped. But Dr. David Samadi, associate professor of urology and chief of robotic surgery at Mt. Sinai Medical Center, points out that waiting to remove the tumor and repair the kidney would be unwise in an unstable patient.
All surgery should be done at the time of the laporotomy if the patient is still bleeding, he says. The patient’s bowels and blood vessels should be examined for damage, and the adrenal vein (and artery) should be clamped during surgery to prevent hormone surges.
If the surgeon can find the precise source of the bleeding, an initial attempt can be made to repair the kidney, Samadi says. But with a deep laceration from a gunshot would, especially in an unstable patient, the kidney would likely have to be removed. The delay by the Miami surgeons could have cost young Kate her fictional life.
The delay in treatment seems to be for the sake of drama rather than surgical necessity, but most of the medical facts in the show are on target.
Siegel is an associate professor at New York University’s School of Medicine.