The Unreal World: ‘Miami Medical’ accident injuries and surgeries a stretch?
” Miami Medical”
CBS, Friday, July 2, 10 p.m.
Final episode: “Medicine Man”
The premise: A school bus crash in the Florida Everglades hurls teacher Lori Wilson (Elizabeth Ho) into a canal and damages the spine and brain of 16-year-old Ben Sims (John Bain). They’re both brought to the trauma center at Miami Medical for treatment. When Lori’s hands swell and she develops a sudden inability to find words (dysphasia), Dr. Chris Deleo ( Mike Vogel) struggles to figure out what’s wrong with her. An MRI of the brain is normal. He finally discovers that she has a very low sodium level (hyponatremia) from swallowing too much water in the canal and, when he treats her with hypertonic (3%) intravenous sodium chloride, she improves.
FOR THE RECORD:
Unreal World: A column in the July 12 Health section about the show “Miami Medical” omitted the name of the actress playing neurosurgeon Abby Sandoval. The actress is April Grace. —
Meanwhile, a CT scan shows that Ben has been “internally decapitated” from the accident, with the occipital area of his brain disconnected from his spinal cord. But his spinal cord is intact, and his pupils are reactive, so neurosurgeon Dr. Eve Zambrano ( Lana Parrilla) thinks he may recover with surgery. She calls in neurosurgeon Dr. Abby Sandoval, who prepares to reconnect the brain and spine and insert a stabilizing rod. The surgeons also learn that Ben had been experiencing tingling and numbness in his hands and feet prior to the accident due to a cyst in his spine (syringomyelia). Zambrano wants to have the cyst drained while the decapitation is fixed, but Sandoval is reluctant to do both at the same time.
FOR THE RECORD:
Unreal World: A column about the show “Miami Medical” in Monday’s Health section omitted the name of the actress playing neurosurgeon Abby Sandoval. The actress is April Grace. —
When Ben suffers a brain-stem stroke, he has to be rushed to surgery. In the course of the operation, Zambrano nicks the cyst with a surgical instrument, forcing a repair.
The medical questions: Can swallowing canal water lead to a low level of sodium in the blood, swollen hands and difficulty finding words? Would this be a difficult diagnosis to make and would the treatment be a 3% sodium solution? Can a patient be “internally decapitated” — and yet have surgery to repair the injury? Can a brain-stem stroke be reversed or be treated during surgery? Can a symptomatic spinal cyst be repaired during emergency brain surgery? Could the cyst be damaged during surgery?
The reality: Drinking a large quantity of pond water could dilute the blood and lead to hyponatremia, says Dr. Dale Lange, neurologist-in-chief at the Hospital for Special Surgery in New York. And fluid-swollen, or edematous, hands could result — as could dysphasia (difficulty communicating or comprehending) because of swelling in the brain, Lange says. But the condition would much more likely be associated with tap or bottled water; canal water is not typically as hypotonic. And a very low blood-sodium level is much easier to diagnose than the show suggests. The sodium level would be part of routine tests for accident victims.
It’s also quite implausible that an accident victim would “sit in the middle of a canal swallowing water,” says Dr. John R. Adler Jr., professor of neurosurgery at Stanford University School of Medicine. It is far more likely that the water would be inhaled into the lungs, drowning the person, he says. The treatment for very low sodium can be a 3% salt solution slowly administered intravenously, but it’s a risky move that can cause severe damage to the covering of the brain stem nerves. A much lower concentration of 0.9 % salt solution would be more commonly used unless the problem is severe.
As for internal decapitation, such an injury is indeed possible — as is surgical treatment, says Dr. H. Louis Harkey, chairman of neurosurgery at the University of Mississippi Medical Center. “I have two patients that suffered this injury and were initially incomplete quadriplegics who are essentially normal now,” he says. Surgical repair generally involves brain-spinal fusion using titanium or steel plates and rods, as the show indicates.
And although brain-stem strokes are life-threatening and difficult to treat, the symptoms of a stroke (even to the brain stem) can sometimes reverse if the problem is due to diminished blood flow rather than complete cessation of flow, Adler says.
If the problem is due to a clot in the artery supplying that part of the brain, the clot might be removed during surgery but, according to Harkey, this is generally only done with ongoing strokes that involve the front of the brain rather than the brain stem. So an intra-operative repair of the stroke is extremely unlikely.
It would take a terrible “slip” to nick the spinal cyst, Harkey says, because the surgery to stabilize the decapitation does not require removal of the bone covering the spinal cord. “A syrinx [spinal cyst] is not like a blister where a small puncture would cause it to deflate,” Harkey says. “You have to cut the cord to get to it.” The elective treatment of the cyst is to drain it, and Adler says that it would be a “dumb idea” to do that at the time of a major brain surgery.
Siegel is associate professor of medicine at New York University’s Langone Medical Center. In the Unreal World, he explores the medical reality of fictionalized TV and film.
