The Unreal World: ‘Three Rivers’ firefighter suffers lung damage
“Three Rivers”
8 p.m. June 19, CBS
Episode: “Every Breath You Take”
The premise: Firefighters Lance Carlyle (Brian Goodman) and Patrick Moss ( Jermaine Williams) are brought to Three Rivers Medical Center after suffering smoke inhalation and airway burns while fighting a fire. Despite oxygen treatment, Patrick remains short of breath, and his blood-oxygen saturation drops to 60%. The doctors learn that he has been suffering from joint aches, cyanotic fingertips (in which the fingertips take on a blue tinge) and rashes, including red bumps on his legs.
Dr. Miranda Foster (Katherine Moenning) and Dr. David Lee ( Daniel Henney) attempt to improve Patrick’s breathing by making an incision in his chest wall. He has significant burns and tissue damage, which are restricting his lungs’ ability to expand, but the move fails to help him breathe more easily or to improve his oxygen level. When his blood pressure drops, they suspect blood may be building up in the sac around the heart and constricting it (a condition known as pericardial tamponade). But when a needle inserted into the chest withdraws straw-colored fluid, not blood, the team decides that Patrick is suffering from the inflammatory lung condition sarcoidosis, made worse by smoke inhalation. They treat him with intravenous steroids (solucortef) and he improves.
Meanwhile, Lance continues to do poorly. Not only have his airways been burned, but 20 years of recurrent smoke inhalation have impaired his lungs. He needs a lung transplant to survive, but no lungs are available in the U.S. for anyone of his blood type.
In hopes that an organ will eventually be found, transplant surgeon Andy Yablonski inserts an ECMO device in an artery and vein to filter and re-oxygenate the blood. But Lance is soon deemed to be too sick with too much preexisting lung damage to qualify for transplant. Andy decides to use a new technique, which he says was pioneered at USC, in which a lower lobe from each of two compatible living donors are used. Donors will lose 10% of their lung function, but Lance may survive.
The medical questions: Does sarcoidosis cause rashes, joint problems and fluid buildup around the heart along with lung damage? And would it interfere with recovery from smoke inhalation? Would steroids be given to a victim of a fire who also has sarcoidosis? Would a patient be deemed not to be a candidate for lung transplant because of the extent of preexisting damage? What is ECMO, and would it be useful as a temporizing measure in this situation? Can transplant surgeons implant two partial lungs instead of one or two whole lungs?
The reality: Sarcoidosis is an inflammatory disease that can cause skin rashes (erythema nodosum), joint inflammation and pericardial inflammation (affecting the sac around the heart), says Dr. Frank Adams, a pulmonologist and police surgeon experienced in treating smoke inhalation for the New York Police Department. But the disease rarely causes pericardial tamponade (in which fluid buildup constricts the heart).
Sarcoidosis primarily produces lung inflammation, which progresses to scarring, Adams says, making recovery from smoke inhalation more difficult. The most effective treatment is corticosteroids, which also can be used in smoke inhalation to reduce swelling in the airways.
But Dr. Shawn Skerrett, an associate professor of pulmonary and critical care medicine at the University of Washington, says that a patient wouldn’t respond as dramtically as Patrick did to steroids, that such an improvement would take several days and that steroids for use in smoke inhalation is speculative at best as “definitive studies are lacking.” Further, because steroids can reduce the body’s immune response, they’re unlikely to be used in burn victims because of the risk of infection, he says.
Adams says they could be used in conjuction with antibiotics, but he points out that someone suffering from smoke inhalation faces an increased risk of pneumonia, which doctors must take into account when considering steroids.The extent of damage to an individual’s lungs would not disqualify that person from a transplant. But Lloyd Ratner, transplant surgeon and professor of surgery at Columbia University, says lung transplants generally involve an extensive evaluation process and would not be done immediately after an acute injury.
ECMO (extracorporeal membrane oxygen) machines are similar to heart-lung machines used in cardiac surgery. They are generally used in newborns with respiratory distress but can be used in adults on ventilators with persistent low oxygen levels. They have been used in patients awaiting a lung transplant.
As for living-donor surgery, partial-lung transplantation was developed at USC in 1994 and has been used as an alternative to single or double lung transplantation with a similar outcome, Skerrett says. It offers a five-year survival of 50%. As the show depicts, two living donors each provide a lobe of one of their lungs.
Ratner says that the procedure was more common when it was first developed, until it was decided that it wasn’t worth the risk to two donors. Now it’s done only a few times a year, usually in parents donating lobes of their lungs to their children (primarily in cases of cystic fibrosis).
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.