Medical Critique: CBS Drama Hostages 2/2

This week, I'm medically analyzing the CBS drama Hostages. In the previous post, that you can find here, I said I'd give them some kudos . . . and I will . . . I promise, but it will come at a later time because I'm having too much fun dissecting this episode.

These posts do have spoilers . . . you have been warned.

Last post I discussed the first three issues I had with the episode and they are as follows:

1. Gunshot wound victims are at high risk of dying from blood loss-- not heart arrhythmias.
2. Physicians don't carry hospital grade defibrillators in their back pockets. Maybe Tom Cruise does but I digress . . .
3. Physicians are generally not comfortable operating a defibrillator. This is generally a nursing function once the physician prescribes the amount of electricity he wants delivered.

Onward we go.

Issue Four: After the husband is "brought back to life" Ellen, played by Toni Collette, goes about diagnosing his problem. Keep in mind she's a cradiothoracic surgeon. Now, she will have gone through a general surgery rotation but her specialty will be everything above the diaphragm.

Her husband has a wound to the left upper quadrant of his abdomen. She sticks her finger into the wound-- perhaps up to the first knuckle and declares, "Your renal vein has been severed." or something relatively close to that.

Wow. Just . . . wow.

Your kidneys lay in your mid-lower back. I like the image here a lot and it comes from the noted website. I think this website is AWESOME. There aren't any gory pictures but it has several photos of drawings similar to this one that shows the anatomy as it lies under the skin drawn with ink.



This is how we think in medicine. We say . . . "The patient was shot here . . . what is underneath or along the tract that could be damaged." And from that we order labs, x-rays and advanced imaging like CT.

In reality, there is no possible way to diagnose a renal vein severing with a finger probe to the front of the abdomen . . . or to the back of the abdomen. This needs advanced imaging techniques. Now, there is some gross (not as in yucky) techniques that could likely lend to the diagnosis of injury somewhere along the GU tract. Blood in the urine. Perhaps urine leaking out of a wound. But to be so specific needs advanced imaging.

http://meded.ucsd.edu/clinicalmed/abdomen.htm

And I can't imagine suturing that vein closed with the patient awake and moving around. Those suckers are small.

I actually do think there would have been a better injury to give this character's husband that would have been more in her skill set and MORE dramatic and that is the tension pneumothorax.

A tension pneumo could easily happen in a gunshot wound to the chest. The lung is hit and leaks air into the chest cavity. If enough air accumulates in the chest it actually pushes or shifts the chest organs (lungs and heart) to the unaffected side (imagine a balloon blowing up in the affected side.)

Treatment for this type of injury is a chest tube and could be fashioned from something from the home and perhaps something from her medical supplies. You'd need a large size tube-- they are big-- think maybe 1/2 the size of a diameter of a garden hose and come in various sizes. Once placed, she could secure it with sutures and place the end in water lower than the patient so air didn't get back into the chest.

To diagnose-- you listen to breath sounds. There are no breath sounds on the affected side. Tracheal deviation-- which means the trachea is shoved to the unaffected side. There are also temporary measures that can be done until a chest tube can be placed-- like sticking a needle in the chest. Then she could have figured out what she needed to fashion a chest tube.

Often times, when I spend time interviewing an expert, I have always come up with a better scenario, and a more realistic one than what I imagined would be good.