9 p.m. Jan. 5, ABC
9 p.m. Jan. 5, ABC
Dr. Teddy Altman (Kim Raver) is operating on a patient who came to the hospital for spinal fusion surgery but now is having heart problems. It turns out that a screw came loose and traveled to her heart, where it sliced the muscle in several places. Teddy tries to sew the heart back together, but she can't get good access to the mitral valve because of scarring. When a suture falls off, she decides to remove the entire heart from the patient's chest, repair it in a bowl of ice and then sew it back in.
Teddy doesn't yet realize that her husband, Henry Burton (Scott Foley), died during surgery to remove a tumor in his lungs. In the previous episode, her resident, Dr. Cristina Yang (Sandra Oh), was asked to perform the surgery, but the attending physicians decided to conceal Henry's identity so that Cristina wouldn't feel inordinate pressure. Now Teddy insists that Cristina assist her with the heart repair because she is the only surgeon available with the necessary expertise. This makes Cristina uncomfortable, since Teddy does not yet know that Henry died.
Meanwhile, Dr. Meredith Grey (Ellen Pompeo) is attending to a family that was in a car crash. Everyone is severely injured except for the oldest child, Lily (Stella Maeve). Her mother and grandmother die of their injuries, and her father and two siblings are treated at the hospital. After watching her father suffer multiple cardiac arrests, Lily asks Meredith to stop using heroic measures to revive him. Since it is her 18th birthday and she is a legal adult, the doctors follow her wishes.
The medical questions
Do surgeons ever remove a patient's heart from the body to get better exposure? Could a screw from spinal surgery ever break loose and lodge in the heart? Would doctors follow the wishes of an 18-year-old who asks for her father to be removed from a respirator? Is it ethical to hide a patient's identity from a surgeon in the operating room? What about withholding devastating personal news from a surgeon during an operation?
Surgeons would not have to remove a heart in order to repair the mitral valve if it can be fixed, says Dr. Edward B. Savage, chairman of cardiothoracic surgery at Cleveland Clinic Florida. "The only scenario where I know of the heart being removed for surgery is auto-transplantation to remove large tumors," he says. Dr. Abe Deanda, chief of cardiothoracic surgery at Bellevue Hospital in New York, adds that surgeons likely wouldn't go to such extreme measures to repair the valve and would probably opt to replace it instead. The kind of valve they'd use depends on the patient's age and other factors. For instance, an older patient would generally receive a so-called tissue valve from a pig or a cow, while a younger patient would get a mechanical valve "to avoid the necessity of a redo operation in the future," Deanda says.
As for the screw that supposedly caused the damage in the first place, Savage says he simply cannot imagine that a screw from spinal surgery would break off and lodge in the heart. Deanda agrees that the scenario is unrealistic and adds that, even if an object could theoretically travel through the veins to the heart, it would get lodged on the right side of the heart, not on the left side where the mitral valve resides.
Though an 18-year-old has the legal right to make medical decisions for her father, real doctors would never put her in that position because of the overwhelming feelings of guilt that might follow, says Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania. Instead, they would assess the futility of the situation and make the decision to take him off the respirator for medical reasons before giving her an opportunity to "dissent rather than consent," he says. Though an 18-year-old is an appropriate decision-maker in this case, adds Dr. Neil Wenger, director of the UCLA Healthcare Ethics Center, she would only be asked to do so with guidance from her father's doctors.
A patient's identity should never be concealed from a doctor and wouldn't happen in real life, Caplan says. Not only is it ethically inexcusable, it's impractical for legal and billing reasons and defies common sense, he says. Wenger says that the real issue is that obscuring a patient's identity may interfere with a doctor's ability to access crucial medical information needed in the course of treatment.
Caplan says that there's "no harm" in waiting to deliver tragic personal news to a surgeon. As the characters in the show realized, interrupting the operation could risk a response that might put the patient in jeopardy. According to Caplan, the patient's best interests are not served by telling the surgeon immediately, especially if she is the only one at the hospital capable of performing the intricate heart repair. Wenger agrees, pointing out that, although anyone who loses a loved one has the right to be informed about it immediately, it is still ethical to wait until a lifesaving surgery is completed before informing the surgeon of her loss.
Siegel is an associate professor of medicine at New York University Langone Medical Center. His latest book is "The Inner Pulse: Unlocking the Secret Code of Sickness and Health."