8 p.m. Wednesday, March 10
Episode: “I’m Fine”
The premise: Nurse Chloe Payne ( Michelle Trachtenberg) is taking care of Molly, an 11-year-old who has been admitted to Mercy Hospital with right upper-quadrant abdominal pain and intractable vomiting. When Molly suddenly develops a heart arrhythmia (ventricular tachycardia), Dr. Joe Briggs ( James Van Der Beek), the hospital’s ICU chief, shocks Molly back into a normal rhythm with a defibrillator. He also asks Chloe to administer potassium; he expects the level to be low from vomiting, thus causing the arrhythmia. She refuses to do so without knowing the girl’s blood potassium level first, and Briggs adds potassium to the intravenous solution himself; nurse Veronica Callahan (Taylor Schilling) administers the anti-arrythmic drug lidocaine.
Molly is stabilized, but she continues to have low-grade fever (100.2 degrees), a rapid heart rate (122 beats per minute) and abdominal pain. When Veronica finds her in the bathroom on the floor with a bloody sheet around her legs, the medical team learns that the girl is having her period and has had a tampon in for more than a day. Dr. Dan Harris (James Le Gros) finds signs of infection in the cervix, but while checking a vaginal specimen under the microscope, he finds gonorrhea instead of, as expected, the bacteria that cause toxic shock syndrome.
Veronica’s mother, Tammy, claims the girl has been having sex with boys in her grade. An ultrasound shows that the gonorrhea has spread to the capsule of her liver (a condition called Fitz-Hugh-Curtis syndrome) and she is started on intravenous antibiotics. Ultimately, Molly tells Veronica that her mother has been pimping her out as a prostitute to make money.
The medical questions: How would a young patient’s right upper-quadrant abdominal pain and vomiting be evaluated at the time of hospital admission? Would ventricular tachycardia, accompanied by severe vomiting, be treated with potassium without a blood-potassium test? Would a nurse refuse a doctor’s order to do so? How is gonorrhea usually diagnosed? What is Fitz-Hugh-Curtis syndrome and how is it treated?
The reality: Dr. William L. Risser, director of adolescent medicine at the University of Texas Medical School at Houston, says he would consider hepatitis, pancreatitis or pelvic inflammatory disease as the most likely causes of such pain and vomiting in an 11-year-old. He would order liver blood tests, plus pancreas and hepatitis tests — and maybe an abdominal ultrasound or CT scan to look for infection, abscess or another disease, he says.
As for the girl’s potential need for potassium, treating ventricular tachycardia with potassium is reasonable — considering the prolonged vomiting — even without knowing the blood level of the mineral, says Dr. Sandeep Jauhar, director of the heart failure program at Long Island Jewish Medical Center. An order to administer it wouldn’t violate norms of professional behavior, he points out, so a nurse would be unlikely to refuse it.
On the other hand, a potassium level can be checked in a matter of minutes, and Sandy Summers, executive director of the advocacy group Truth About Nursing, disagrees with Jauhar that a nurse would be expected to give potassium in this situation without knowing the level first. “Nurses are legally and ethically obligated to do what they think best for the patient,” she says. A nurse is not required to comply with a physician’s order if he or she believes it could harm the patient.
Now about that gonorrhea diagnosis: A vaginal specimen can be used to diagnose the disease, but it isn’t reliable, Risser says. The specific organisms are easy to miss under the microscope; a culture is more reliable, though it too is negative in 40% to 60% of cases.
As the show suggests, Fitz-Hugh-Curtis syndrome is an inflammation of the capsule of the liver due to pelvic inflammatory disease. Curable with intravenous antibiotics, it’s most often caused by the bacterium chlamydia but also can be caused by gonorrhea. An estimated 4% to 14% of women who have pelvic inflammatory disease develop Fitz-Hugh-Curtis syndrome, so the show’s main diagnosis is believable, even if the care the patient receives isn’t.
Siegel is an associate professor at New York University’s School of Medicine.