The Unreal World: A brain injury, then a nightmare in the ambulance

“Law & Order: Special Victims Unit”

9 p.m. Dec. 1, NBC

Episode: “Rescue”

The Premise: Twenty-six-year-old Caitlin Lemarck throws a party at which she is attacked, and her head is smashed against a mirror. She has a seizure and is taken to the hospital, where she goes into cardiac arrest. The emergency room doctors aren’t able to resuscitate her, and she dies of bleeding into her brain (a subdural hematoma). Upon examining Lemarck’s body, Dr. Melinda Warner ( Tamara Tunie), the New York City medical examiner, discovers injury and other evidence that leads her to believe that Lemarck was raped by one of the paramedics, Tinta, who brought her to the hospital. Tinta admits to the crime while speaking to his partner Mike, who is secretly taping the conversation. Tinta, discovering that he is being taped, tries to commit suicide by injecting air into his jugular vein, and he loses consciousness.

Medical questions

On what basis would head trauma cause a seizure? What is a subdural hematoma and how frequently is it fatal? What emergency diagnostics and intervention could help save a patient after severe head trauma? Would injecting a vein with air cause death?

The reality

Seizure is common in head trauma, caused when the force of a blow interrupts the brain’s electrical pathways, says Dr. Mark Morocco, UCLA associate emergency medicine residency director. Subdural hematoma is bleeding into the space between the dura — the “bag” that surrounds the brain — and the brain itself, Morocco says. It is usually caused by the shearing of veins that bridge the brain and skull. Death occurs in approximately 50% of cases.

Immediate transport to the highest level hospital possible — one with neurosurgical services — is essential, Morocco adds. The patient is generally placed on a breathing machine (respirator) and given diuretics to decrease pressure in the brain, as well as anti-seizure medications. A CT scan of the brain must be performed right away and the blood or blood clot removed by a qualified neurosurgeon, says Dr. Billy Goldberg, assistant professor of emergency medicine at New York University Langone Medical Center.

Morocco and Goldberg say they’ve never heard of a case of behavior like this by a paramedic, though they assume it must exist. “You are far more likely to die because the ambulance crashes on the way to the hospital than being raped or robbed by the paramedic,” Morocco says.

Injecting a vein with air is unlikely to cause death, Goldberg says. When a vein is injected with air, the bubble would go from the right side of the heart into the lungs, where it would cause significant cell death from lack of oxygen only if the blockage was severe enough. But even in that case, it would be very unlikely to be fatal.

Siegel is an associate professor of medicine and medical director of Doctor Radio at NYU Langone Medical Center.

marc@doctorsiegel.com