When the residents run amok on ‘Grey’s Anatomy’

“Grey’s Anatomy”

9 p.m. Oct. 21, ABC

Episode: “Almost Grown”

The premise

Chief of Surgery Dr. Richard Webber ( James Pickens Jr.) puts Seattle Grace Hospital’s senior residents in charge for a day while he meets with the attendings about ways to spend a $1-million grant. Resident Jackson Avery ( Jesse Williams) places a shunt tube into a patient’s brain to relieve pressure that is causing headaches and ringing in the ears, but when the tube slips, seasoned neurosurgeon Derek Shephard ( Patrick Dempsey) has to take over. Resident Alex Karev ( Justin Chambers) is assigned to the case of 13-year-old Seth Gruberman (Jarrod Bailey), who has gynecomastia (abnormally large breasts in a male), and he helps the boy and his mother decide that a breast-reduction procedure will help make him feel “normal.” Karev then performs the operation. Resident Lexie Grey ( Chyler Leigh) is following a woman with a broken leg who is receiving blood thinners to prevent a dangerous blood clot. She suddenly develops a headache, blurred vision and left arm numbness, and resident Meredith Grey ( Ellen Pompeo), acting as the neurosurgery consult, concludes the blood thinners caused intracranial bleeding and takes the patient to the operating room. Meanwhile, residents April Kepner (Sarah Drew) and Cristina Yang ( Sandra Oh) treat a 57-year-old man who will soon die unless he gets a double- lung transplant. But he has pulmonary artery hypertension, a poorly functioning liver, is being treated for fungal pneumonia and is developing kidney failure. Nevertheless, Yang persuades the hospital’s transplant board to put Henley on the list because she believes he has a strong will to survive.

Medical questions

Is it safe to put senior residents in charge of patients, even temporarily? How common is gynecomastia in boys, and is it generally repaired surgically? Can blood thinners cause bleeding in the brain that leads to headaches, blurred vision and arm numbness, and is it fixed with surgery? Would a patient with severe pulmonary hypertension be a candidate for a double-lung transplant? Would he be excluded for poor kidney or liver function but then chosen based on his “will to fight”?

The reality

There is a hierarchy among physicians at academic medical centers, with attending physicians at the top, followed by fellows, residents, interns and medical students, says Dr. James P. Bradley, chief of pediatric plastic surgery at the David Geffen School of Medicine at UCLA. “There are times when chief residents have to step up, but a hospital would not be abandoned by the attendings to let the residents run amok.”

A senior resident could safely place the type of shunt given to the patient in the show to drain fluid from the brain, says Dr. Anthony Frempong-Boadu, assistant professor of neurosurgery at New York University Langone Medical Center, since it is a “relatively straightforward procedure.”

A patient with gynecomastia would get an endocrinological work-up, but it may not show a cause, Bradley says. More than half of boys develop mild cases during adolescence, according to the National Institutes of Health. A moderate or severe condition would be treated surgically, with liposuction used for limited cases and open surgery when there is marked breast tissue, as the show depicts.

Blood thinners after surgery can cause bleeding between the lining of the brain and the brain itself, which is known as a subdural hematoma, Frempong-Boadu says. The increased pressure on the brain can cause these symptoms and require rapid removal of the accumulated blood after reversal of the blood thinners, he adds.

Thanks to advances in medical therapies for pulmonary artery hypertension, only 5% of lung transplants in the U.S. are done for this reason, and these involve patients who fail to respond to medications, says Dr. David Ross, medical director of the lung transplant program at UCLA. But kidney or liver dysfunction or inadequately treated infection are considered contraindications to transplant, Ross says. “Although inspiring, the patient’s will to live is not taken into consideration.” Dr. Aldo Iacono, medical director of the lung transplant program at the University of Maryland Medical Center in Baltimore, adds that it is “nearly universal” not to list a patient with progressive renal failure on a lung transplant list unless the kidney problem is corrected first. At the same time, if the kidney and liver problems are expected to improve with the improved circulation following the transplant, the patient may be considered.

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

marc@doctorsiegel.com