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THE UNREAL WORLD

A good nurse has 'Mercy'

October 19, 2009|Marc Siegel

"Mercy"

NBC, 8 p.m. Sept. 23

Episode: "Can We Get That Drink Now"

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The premise

Veronica Callahan (Taylor Schilling) has returned from Iraq suffering from post-traumatic stress disorder, for which she is taking the antidepressant Paxil.

Even with treatment, she is frequently irritable and has flashbacks to the war. She has taken a nursing position at Mercy Hospital, where she takes charge of cases the way she did in Iraq.

At the scene of a car accident in which the driver sustains a tension pneumothorax (a deflation and collapse of a lung), Veronica assumes control of his care after a dermatologist nearby declines to do so. She makes a hole in his "fifth intercostal space" (in between the ribs) with a needle and then inserts a straw through the hole, feeding it into a soda bottle and, as air is sucked out of his chest cavity, his lung reexpands.

At the hospital, Dr. Dan Harris (James LeGros) criticizes her actions at the site, saying that a doctor, rather than a nurse, should be managing a trauma case.

Shortly thereafter, gunshot victims are brought to the emergency room; one of them, a 15-year-old boy, has a cardiac arrest but is resuscitated. He has a bullet lodged in his hip and develops a rash on his chest. Veronica is convinced he may have a fat embolism (in which fat enters the bloodstream from a wound, usually because of a severe trauma) and suggests he be given the blood thinner heparin. An ER resident disagrees, though Veronica insists that heparin was used on the "front lines" for this type of situation and that studies show that such treatment can help patients recover. The boy ends up dislodging the embolism to the lungs as Veronica predicted, has trouble breathing and sustains severe brain damage from lack of oxygen.

Finally, one of Veronica's patients, a 60-year-old woman dying of metastatic liver cancer, is subjecting herself to further surgery and chemotherapy only to placate her adult children. Veronica tells the surgeon privately that his treatment is "snake oil." When the patient asks her opinion, Veronica asks her to reconsider the therapy, saying the surgery is not likely to add to the quality or quantity of her life.

The medical questions

Is Paxil a good treatment for PTSD? Is it reasonable to treat a tension pneumothorax by jamming a needle, then a straw, into the chest? Did Veronica overstep her bounds at the accident scene? Might her forceful behavior be the result of PTSD?

Is a gunshot to the hip a likely cause of a fat embolism in the lungs -- and is a rash on the chest a telltale sign? Is heparin an effective treatment? Would a nurse generally be expected to counsel a terminal cancer patient to withdraw further treatment while criticizing a surgeon for offering it?

The reality

Paxil is an effective treatment for PTSD, says Rachel Yehuda, professor of psychiatry and director of the traumatic stress studies division at the Mount Sinai School of Medicine. The condition can make people irritable, explosive and easily startled, Yehuda adds.

It is unlikely, however, that PTSD would drive Veronica's medical responses in the field, says psychiatrist Dr. Keith Ablow. More likely, the PTSD would render her emotionally numb and unable to perform.

Inserting a needle into the chest cavity to relieve a tension pneumothorax is a fairly common procedure done by paramedics and can certainly be done by a nurse, says Dr. Demetrios Demetriades, director of trauma, emergency surgery and surgical critical care at USC Medical Center. But there is usually "no need for any other tricks such as other tubes," he says. "Plus, the soft straw would never make it through the chest muscles from a needle cut to the skin. You would need a generous deep cut with a scalpel."

As for performing the procedure herself, clearly she was qualified to do so, says Sandy Summers, a nurse and the executive director of the Truth About Nursing, a nursing advocacy group. And it was prudent for her to make the medical decisions, particularly when the dermatologist, who lacked the expertise, declined.

The gunshot victim's case, however, is largely unrealistic, Demetriades says. First, such a patient would never sustain a cardiac arrest soon after the accident unless there was severe bleeding; second, because a fat embolism usually occurs a few days after multiple fractures, not immediately, and seldom from a single gunshot wound. And although heparin has been used in the treatment of fat embolisms, Demetriades says, studies have not shown it to be effective. Giving heparin to patients on the front lines could even cause patients to bleed to death.

He acknowledges, however, that a fat embolism (if it does occur) can cause a rash, because the capillaries of the skin are occluded with fat.

Veronica's interaction with the terminally ill patient is more appropriate. "It is a crucial nursing role to provide psychosocial counseling to patients," Summers says. "As patient advocates, nurses are ethically bound to fight for their patients." And yes, she is right to give her opinion to the surgeon privately.

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Siegel is an associate professor of medicine at New York University's School of Medicine. marc@doctorsiegel.com

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