The Unreal World: 'Private Practice'

Looking at the dangers represented in 'Can't Find My Way Back Home' episode.

November 29, 2010|Marc Siegel | The Unreal World

"Private Practice"

10 p.m. Nov. 18, ABC

Episode: "Can't Find My Way Back Home"

The Premise: Sharon, a widow in her 40s, has been having severe seizures for more than seven years. Neurosurgeon Amelia Shepherd (Caterina Scorsone) is able to locate the scar from an old brain lesion that is causing the seizures, and she offers to insert a probe that will emit "radio waves to heat and ablate the scar." Amelia tells Sharon that the repeated seizures will result in brain damage over 10 to 15 years if left untreated. However, according to Amelia, the procedure itself could lead to partial paralysis or blindness since the scar is near the motor and visual centers of the brain. Sharon decides to take the risk and the procedure is successful.

Meanwhile, Dr. Charlotte King ( KaDee Strickland) acknowledges that she was raped during a recent attack at St. Ambrose Hospital in Santa Monica, where she is chief of staff. At first she's afraid to go to the police station to identify the rapist in a lineup. Charlotte gains the courage to turn him in when she learns he has a girlfriend with a son who may also be hurt.

The medical questions: Do severe seizures cause brain damage over time? How can the focus of the seizure be located? Can a probe be used to destroy the scar with radio waves? Is there a risk of blindness and paralysis? Why is it hard for rape victims to identify their attackers when they know that others may be in danger? Do they have an ethical responsibility to report the rapist?

The reality: There is evidence that severe seizures can cause brain damage, says Dr. Jerome Engel Jr., director of the UCLA Seizure Disorder Center. The cells may be overstimulated beyond their ability to cope. Removing the seizure focus in such a case is a reasonable consideration.

Locating a seizure focus is not simple, according to Dr. Marc Nuwer, director of clinical neurophysiology at UCLA. The process involves several hours of EEG monitoring to catch multiple seizures, as well as an MRI of the brain, a PET scan and cognitive testing. "Without the whole battery, the brain surgeon is not likely to pick the right place," Nuwer says.

According to Engel, a probe that emits radio waves to destroy the scar is a very old and ineffective treatment that is no longer used and was never used for lesions in the cortex of the brain, like Sharon's.

A gamma knife (not an actual blade but a focused beam of radiation that can slice through tissue like a knife) can destroy a seizure focus but generally isn't used for lesions involving the cortex, Engel says. In those cases, surgical resection is still the best option, and complications — though possible any time brain tissue is destroyed — are quite rare.

Though doctors should tell patients about the risks of any procedure to get their informed consent, Engel says that warning Sharon about looming blindness and paralysis is part of the show's "outlandishly ridiculous plot."

For one thing, the visual and motor centers of the brain's cortex are not in the same place, so the show's writers "should have picked just one" in order to be believable, says Dr. Orrin Devinsky, director of the Comprehensive Epilepsy Center at NYU Langone Medical Center. For another thing, the risk of significant motor loss from a careful operation to remove a seizure focus is extremely small. And if the visual cortex at the back of the brain were affected, Devinsky says, loss of vision would only be partial.

A rape victim may experience a physiological response or instinct that kicks in and provokes her to flee rather than confront her attacker, Newer says. Everyone shares a duty to prevent harm to others and to get rapists out of the community, adds University of Pennsylvania bioethicist Arthur Caplan, but sadly, the sense of "stigma and social ostracism" can be difficult for women to overcome.

Most states, including California, have laws that require physicians to report reasonable knowledge or suspicion of rape. That would not apply to Charlotte because she was the victim in this context, not the doctor.

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

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