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The Unreal World: Patient from death row complicates ER

The 'Afterglow' episode of "HawthoRNe" raises questions about treatment of a Chiari malformation, seizures and the ethics of treating a condemned man.

August 09, 2010|Marc Siegel | The Unreal World

The Premise: Calvin Jenkins ( Robert Wisdom), an inspirational speaker and musician, is on death row for the murder of a pastor. He is brought to the ER at James River hospital after experiencing recurrent seizures in prison. A brain MRI reveals a Chiari malformation, an abnormality of the lower part of the brain that causes it to slip downward. Jenkins needs surgery, but this is not available in the prison. The hospital administrator feels that operating on Jenkins will financially benefit the hospital. He has arranged for a neurosurgeon (Dr. Clay) to operate, but director of nursing Christina Hawthorne ( Jada Pinkett Smith) and surgeon Tom Wakefield ( Michael Vartan) are reluctant to take care of a patient who is due to be executed in about nine months. In the ER, Jenkins has a seizure, and Dr. Steve Shaw (Adam Rayner) orders a CT of the head and starts him on the anti-epileptic drug Dilantin to treat his seizures. He is admitted to the hospital for surgery, but his symptoms progress: His left side becomes numb and he smells "burnt toast." The doctors believe that if he isn't operated on soon, he will die.

The Medical Questions: What is a Chiari malformation? Can it cause seizures, numbness and a change in the sense of smell? Is it a life-threatening condition? Can the seizures be controlled with Dilantin? Are there ethical reasons to not operate on a patient on death row whose execution is likely to occur within the year?

The Reality: A Chiari malformation is a deformity, present since birth, that most often results from the rear of the brain (posterior fossa) being too small to contain the lower cerebellum, which then herniates out of the skull and pushes on the upper spinal cord. The malformation is almost never life-threatening except in rare cases when it causes apnea (suspension of breathing), aspiration pneumonia (from breathing in foreign material) or a drop attack (sudden loss of muscle tone), says Dr. David Frim, chief of neurosurgery at Comer Children's Hospital of the University of Chicago. Seizures rarely occur — and are not usually seen in someone as highly functioning as Jenkins, says Dr. Anthony Frempong-Boadu, assistant professor of neurosurgery at New York University's Langone Medical Center. Nor would this condition generally cause problems with the sense of smell, Frempong adds, though the pressure on the top of the spinal cord could cause hand numbness and loss of coordination. The one-sided numbness that Jenkins experiences could also be a residual effect of the seizures (a condition known as Todd's paralysis).

A decompression operation is highly effective at reducing the effects of the malformation, Frim says: Pressure against the lower part of the brain is relieved by opening the back of the skull. The lining of the brain is also expanded (a duroplasty), creating more room for the brain.

Seizures are often treated and controlled with Dilantin (phenytoin), Frempong says, but in the ER you would first use a benzodiazepine such as Ativan (lorazepam) to stop the seizure.

There are ethical reasons to operate on a patient on death row, says Arthur L. Caplan, director of the Center for Bioethics at the University of Pennsylvania. "This death row prisoner is to be executed by the state — not by medical neglect," Caplan says. "It is not medicine's responsibility to sort out sinners and saints before giving care."


9 p.m. July 13, TNT

Episode: "Afterglow"

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