Monday, October 12, 2015

Code Black Part II: "It gets worse"

Last week, I reviewed the premier of the new medical television series "Code Black" and pointed out several flawed or impossible scenarios. I didn't think I'd watch another episode.

But I was alerted to a rather shocking error on last week's installment. I had to see it for myself.

On this typically chaotic day in the emergency department, a young woman was brought in after a car crash which occurred while she was in her way to the ED because of abdominal pain. A CT scan of her abdomen and pelvis was negative, but her serum lactate level was elevated. They then decided to examine her abdomen and noted tenderness. A bedside ultrasound done in the ED revealed a left ovarian torsion (twisting of the blood supply to the ovary which if not rapidly corrected, could cause irreversible damage). The patient had already had her right ovary removed. Further heightening the drama was that her husband died of lymphoma but had banked his sperm, and the patient wanted to have his baby.

She needed immediate surgery, but all of the hospital's operating rooms were busy. As the window of opportunity to correct the problem was closing, an operating room opened up. But alas, there was not a single gynecologist or surgeon available to do the case. According to the back story about Dr. Neil Hudson, he's a fully trained surgeon who decided to work in emergency medicine. One of the new ED residents begged Dr. Hudson to do the case, and he resisted for a while until it was almost too late.

Despite admitting to having no operating room privileges and surely no malpractice insurance coverage for surgery, Dr. Hudson finally acquiesced. Just before beginning the case, he explained to the OR staff what he was going to do.

Then the egregious error occurred. While scrubbed in the OR and wearing a sterile gloves and gown, he calmly reached up to pull his unsterile mask over his nose and mouth. That's a no-no.

PS: I could find no reference mentioning an elevated lactate associated with ovarian torsion. The organ is likely too small for ischemia to have any effect on the that lab value.

Some other highlights. For a patient with multiple facial lacerations, Dr. Hudson ligated the maxillary artery—quite a feat in an emergency room without an OR light or any retraction. As you can see from the figure below, the maxillary artery is deep to the jawbone. Not shown are branches of the facial nerve which lie above the artery.

Dr. Leanne Rorich, the all-knowing equivalent of Dr. House, stopped a nosebleed by inserting Foley catheters in each nostril, a well-known trick. However she inflated the balloons with the closest liquid she had on hand—coffee, and the patient's blood pressure normalized within seconds.

If the convoluted story of the woman with the ovarian torsion wasn't enough, the patient with the nosebleed happened to be a 14-year-old blind boy on Coumadin who fell while rock climbing with his father.

Stay tuned for the next episode featuring a bus that tumbles off a narrow mountain road while carrying non-compliant hemophiliacs.


45 comments:

Vamsi Aribindi said...

Heh,
Did you catch the part where the EM Physician /ex-Surgeon somehow uses the foley to tamponade off bleeding from a vessel in the abdominal cavity accidentally punctured during the operation, as suggested by the 1st year EM resident?

Skeptical Scalpel said...

Yes, I saw that. I didn't mention it in the interest of brevity. I think the bleeder was in the incision. He said "I must have nicked something on the way in."

There is no way you could easily get a Foley catheter into that tract and I doubt it would adequately compress the subcutaneous tissue or the epigastric artery anyway. The only way it would work would be if the surgeon somehow managed to get the catheter all the way into the abdomen. Then the balloon could be inflated (not with coffee) and pulled up against the abdominal wound.

Anonymous said...

Skep, with all respect, I normally read everything from you whether I agree or not. I couldn't do that with this post. There is not enough nausea medication and I don't have IV's to inject it in to read this.

I need to go lay down and take something.

While we are on the subject of illness, maybe a post on how to get the administration (hurl ... ) to stop their bonuses in favor of the medical employees?

Skeptical Scalpel said...

Anon, thanks for commenting. I feel your pain about the shows. I don't like watching them either, but I can't sit there and let the nonsense be shown without saying something.

I've written about hospital CEO salaries in the past. (http://skepticalscalpel.blogspot.com/2013/09/performance-goals-for-hospital-ceos.html)

artiger said...

Someone, please, make it stop...

Skeptical Scalpel said...

I'm doing my best.

Les said...

"Stay tuned for the next episode featuring a bus that tumbles off a narrow mountain road while carrying non-compliant hemophiliacs."

You've got to keep watching!

Skeptical Scalpel said...

Les, I hope you won't be too disappointed to learn that I made up the part about the busload of hemophiliacs.

Anonymous said...

You know, I watched a show that follows some British ambulance service patients (Not St. Johns, I guess that would be plain NHS ambulance? but it doesn't matter) and their subsequent treatment in the hospital.

This guy was squashed by a cow and had a few liver lacerations that needed treatment. They check his entire abdomen because they couldn't see the actual injury and had to view and rule out everything. That makes sense. Then I saw the main surgeon was operation without a face mask. I was gobsmacked.

I have never seen a regular human surgery in an ER be done without a face mask except: 1. in a movie or tv show, where they don't wear it because it works better for the film or 2. when the hospital is in dire straits, like in a war zone and masks have run out or it's in a hurrican or typhoon or tornado and it's operate now, can't find the mask, patient will be dead otherwise. This surgery, while emergent, was not in that kind of situation. Why on earth would a surgeon be poking at a liver with no face mask?

Skeptical Scalpel said...

While some have questioned the need to wear masks in the OR, the standard of care in the US is that masks are worn until the operation has ended and the incision has a dressing on it. To depict surgery the way Code Black did is either sloppy or ignorant. I assume the show has a physician medical consultant, but it is hard to tell for sure.

Les said...

I thought you were doing screen writing for future episodes.

Skeptical Scalpel said...

I don't think they would hire me. My first episode would focus on people who come in at 1:00 AM with back pain that started 3 weeks ago.

Anonymous said...

Oh, and in that liver surgery I described, the head surgeon was the only one to not wear a mask. Every other doctor and nurse and tech had a mask on. That added to my confusion.

I've always wondered how well masks work. Sure, they'll stop a snotty sneeze from spreading. I'm deaf and every surgery I've had, everyone pulls their mask down until I'm out cold so I can understand them. If they had to keep them on all the time to create a more sterile field they wouldn't be pulling them down in the OR to talk to me. I've seen tons of vet surgeries in a variety of offices without masks, but my super modern vet oncologists use them for surgeries. Heck, most vet offices do their surgeries in what is essentially an exam room with a gas machine, not a cold room with special ventilation or anything like that.

That was a very long winded way of asking how effective masks are, of the kind used in operating rooms.

Skeptical Scalpel said...

As far as I know, there has never been a study proving the effectiveness of masks in preventing surgical infections. Small studies have shown no effect, but they are too small to be definitive. I am told that in some European countries, masks are not mandatory.

There's another reason to wear them--self-protection. A surgeon never knows when blood will spurt unexpectedly. When that happens, I'd rather have a mask on than not.

Marty Tousley, RN MS FT DCC said...

Truly, I don't know how you can stand to watch this god-awful show. Still, your reviews are far more entertaining, and I thank you for that!

Skeptical Scalpel said...

I watched parts of two episodes. That's all I could take. I feel it's my duty to warn the rest of you. The show is both infuriating and funny, both of which the creators did not intend.

Anonymous said...

Why are you watching it? It's for entertainment, not education.

Skeptical Scalpel said...

I understand that. The reason I review these shows is that when they are so far from reality (as Code Black is), they create false expectations among non-medical people. Every difficult case is solved within an hour. Surgeons perform miracles. Cesarean sections by first year ED residents take place in ambulance stuck in traffic.

A TV show doesn't have to educate, but it should have some link to what really happens.

Someone must like my reviews. The two I posted about Code Black have received 2800 page views combined.

Marty Tousley, RN MS FT DCC said...

I agree with you completely. Stories like these do far more harm than good, and they are an insult to the physicians, nurses and all those other folks who work in health care and devote their lives to caring for others -- not to mention our patients and their families. Look at Hollywood's portrayal of mental illness over the years.

Skeptical Scalpel said...

Thanks for supporting my views on this.

Lola said...

I didn't make it to the first commercial break. I've never heard the term "code black", but the show's premise is that Angel Memorial Hospital is routinely at a point where resources are insufficient to cover demand. That is a very poorly run hospital, and probably aptly named. Until the administration is replaced with competent management, that hospital will be making a lot of angels.

Skeptical Scalpel said...

Yes. Poorly run. Did they ever hear of "diversion"?

Libby said...

Dang, I was actually going to PVR it so I could see how they dealt with non-compliant hemophiliacs and you go and admit (what I was sure anyways but hoped not) you made it up. Sigh. It would actually make it interesting to watch.

Skeptical Scalpel said...

Yes, that would be an interesting story line. Maybe they'll ask me to send them a script.

Anonymous said...

UK based radiographer here, shouting at the TV when that baby ED doc is in the scan room while the CT is happening and is wearing no lead protection!!! Plus the patient was writhing all over the table during the scan... The following week he's in a general waiting room treating patients; no confidentiality at all.

Skeptical Scalpel said...

The list of transgressions goes on. I think non-medical people, a few of whom I've heard from on Twitter, are watching and it has been picked up for the rest of this season. Non-medical people don't care about all the unrealistic stuff. But it's ratings are not impressive. it's currently doing a 1.2/4 rating/share, which is below average for its network, CBS. http://tvbythenumbers.zap2it.com/2015/11/12/wednesday-final-ratings-nov-11-2015/

Jason Bowen said...

Unfortunately my wife and kids watch it. I'm not even close to a medical type person and I spotted the absolute horsecrap in it. So I landed here and see I'm right. This show should be watched like a Playboy is read, for the stories, cause there definitely aint no meat..lol

Skeptical Scalpel said...

Jason, thanks for your comment. I can't watch it because like most medical TV, it is infuriating.

Thursday O'Connor said...

Stumbled across this... In most cases I know that Code Black typically is used to refer to dead patients, myself having multiple people familial and otherwise in my life partaking in medical based careers. I was irked when I heard their `motto`, so I fled to the internet to confirm the asinine tomfoolery that I had heard. It is 4:am about, and it was quite startling to hear that shenanigans for the first time. I am an insomniac, and I do not watch much TV, but someone left it on tonight, while I was working on my programming. I would like to say, you have made me smile with your comical disdain of YAMS (Yet Another Medical Show) because I feel the same way mostly.

Skeptical Scalpel said...

Thursday, thanks. I must admit these shows make good fodder for blog posts. If you type "television" in the search field of my blog, you can read my reviews of other mostly bad shows.

Anonymous said...

Ummmm, I'm a banker and have no medical background (though my sister manages media relations for several hospitals, does that count?) and this shocked me so much I had to hit the google. I'm watching the episode titled "You Are the Heart" and they're performing surgery on a guy in the ER to remove his spleen (splenectomy, I presume?). NOBODY involved in the surgery (two doctors and three nurses) is wearing a mask. Yes, it's just a TV show, but even I think this is unbelievably ridiculous and maybe even irresponsible. Oh and the guy's injured girlfriend is lying on a gurney nearby watching the surgery. Gotta laugh.

Skeptical Scalpel said...

Anon, thanks for the update on the show. I suppose the ED docs are the ones doing the surgery too. It apparently is getting worse by the episode. I agree that it is both ridiculous and irresponsible. I can't bear to watch it again.

Emily said...

I think medical TV shows take liberties with the lack of face masks so the audience can recognize who's saying what in a talky scene. Not to mention the actors probably want their faces on camera as much as possible.

Skeptical Scalpel said...

I'm sure you are right. The other reason may be that it gets people like me riled up and talking about their show.

"There's no such thing as bad publicity." See http://www.phrases.org.uk/meanings/there-is-no-such-thing-as-bad-publicity.html

Unknown said...

As a future medical student and current medical social worker... these shows kill me. I saw a Chicago Med episode where a young new mom ditched her newborn and the social worker never talked to the girl but called the cops to arrest her from the hospital! What!!?

That would never happen! First, the hospital social worker would meet with the patient and get child protection involved and most likely, since both parties were (of course, because it's TV) 100% healthy after the medical interventions, the infant would discharge home with the young mother and child protection following the case.

I have NEVER seen the cops called to the hospital unless someone either comes in already in custody or escapes on a drug/alcohol/psych hold. In fact, we can't really call the cops. Hospitals are supposed to be safe places. Complete madness, and such a bad portrayal of the social work profession. The social worker said something like "She has to pay the price for what she's done!" as if instead of being an advocate her role was to punish the patient.

And Code Black... I've always known Code Black as a bomb threat, but each hospital assigns their own colors as far as I know. I will say I have heard the Code Black documentary is valid but the show is complete BS.

Skeptical Scalpel said...

Unknown, thank you for your perspective as a social worker. "She has to pay the price for what she's done!" That is so anti-social worker. But if the SW had simply helped the woman, that wouldn't have been as dramatic.

Dash said...

I have worked in EMS for two millenia, two centuries and a handful of decades. All I can say is it is making my brain cry. My wife watches it and shushes me and uses "The look" she used on our children. The next time a doctor jumps into my ambulance and yells "Let's go." Yeaah, doctor. We will depart as soon as you get the hell out. You have GOMER, we have GOMA." I have never seen an MD on scene unless s/he was driving by or it was their office. Never seen one grab a crowbar and begin extrication of an MVA victim in the middle of a multi-casualty incident.

Okay, I'll shush now. I'm getting "The look". How does she know?

Skeptical Scalpel said...

They all know. It's a sixth sense they are born with.

Autumn said...

I'm an RN and I gave up completely on medical dramas once I started working. I've seen bits and pieces that have confirmed my distaste over the years. I also tend to wander off when other shows wander into medical territory. I have to say, regarding Unknown's comment, in many states if you leave a newborn in a safe place and say you are abandoning it you won't be arrested. A hospital is one such place. NYS has this law, as does Florida.

Skeptical Scalpel said...

Autumn, thanks. You are correct that many states have laws not criminalizing abandoning newborns at hospitals, police and fire stations.

Anonymous said...

Have you noticed that the doctors never use a crash cart to revive patients? Is there a reason for that or just another flaw in the show?

Skeptical Scalpel said...

I haven't seen the show since the second episode. I have no idea why they don't have a crash cart. Maybe it would get in the way because they always seem to have a lot of people around.

Also, they tend to use whatever is handy such as inflating the balloon of the catheter with coffee. In most hospitals, coffee is not routinely stocked on a crash cart.

Anonymous said...

Episode from 2-17-16...the surgeon requests a suture (odd at the beginning of a surgery) The nurse hands him a scalpel and doctor makes an incision. Just goes to show you that the nurse always knows what the doctor really needs.

Skeptical Scalpel said...

Thank you for letting me know about that gaffe. I'm going to have to watch the episode now.

When I was a resident, we had some great scrub nurses. We used to say to them, "Give me what I need, not what I ask for." It was sort of joking but had a element of truth to it.

Skeptical Scalpel said...

Anon from 2/19/16, I watched that episode and blogged about it yesterday http://skepticalscalpel.blogspot.com/2016/02/code-black-is-still-on-tv-did-it-get.html

Thanks for the tip.

Post a Comment