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Wednesday, July 23, 2008

A Palliative Care View of "Hopkins"

ABC has been featuring residents from Johns Hopkins University on the reality docudrama "Hopkins" on Thursday nights. The show goes to where the action is by focusing on the emergency department, surgeons, and pediatric ICU. Overall the show manages to capture life as a resident pretty well even following the difficulties outside the hospital for one of the physicians going through a divorce. I had high expectations of palliative medicine being featured during the show given that over 6 hours there would likely be some end-of-life issues cropping up. But after 4 episodes the demonstration of palliative care skills has been mixed.

Have any Pallimed readers been watching this show?

I am curious to how some of you responded to a pediatric intensivist* who suggested to "just let the child die" during a informal doctors conference about a toddler with a dilated cardiomyopathy who had a cardiac arrest during anesthesia induction about to be put on ECMO? You can watch it yourself...EPISODE 4 available online; move to a little less than a quarter of the way through the episode. You have been warned by the way, seeing the child unresponsive and actually coding was very difficult to watch for me even being through lots of codes and seeing deceased, lifeless patients.

Here is the full text of what he said on air (after what was edited I presume by the TV producers):
(In hallway with cameras, alone)

PICU Attending #1: We don't know hom much damage has been done. And there is some disagreement as to whether we can save the heart or not.

(Cut to conference room with lots of doctors, no patients/families)

PICU Attending#2: It is my opinion that we just let the child die. ECMO would be a bad idea. But I suspect that I am in the minority.

#1: Why would you say that? We don't have the biopsy back yet. If the biopsy shows that he has acute myocarditis...then we could...uh..ride him thruough this storm. Now if it shows that he has got..uh you know scar there..well..yeah...then we got a problem.

#2: What do you think the biopsy is going to show?

#1: I agree that this is likely to be old.

(fade to black after seeing them both stand quietly not looking at each other, appearing demoralized.)
Interestingly this is how the above situation is described on the website synopsis:
"let him deteriorate and provide palliative care or attempt a risky heart transplant if one becomes available."
But they never actually talk about palliative care on the show. Can someone else remember where they said 'palliative care?' I can hear those words in the media from a thousand paces.

I think it is important to realize this scene and the doctor's words got a lot of outrage on the Hopkins/ABC website in the Episode 4 Talk Back Q& A section. People are calling for his firing, and saying he should not be a doctor. The child eventually made it through the situation causing more outrage on the message boards. And further anecdotal evidence for the public that 'doctors can be very wrong.' To me this scene is part of the frank discussions physicians may have every day, especially doctors in the ICU. Sometimes opposing views need to be heard even though they may be unpopular to make sure there is justification for the current plan of action. The attending even pointed that out by acknowledging his 'minority' view point.

While palliative medicine as a specialty is lacking on the TV show (Hopkins surprisingly does not have a palliative medicine fellowship), the Hopkins/ABC website has video responses from Dr. Holly Yang from San Diego Hospice about different situations in each episode that could have been approached in a different way. You sometimes might have to scroll through the responses to find Dr. Yang. Too bad they had some audio difficulties with some of her segments.

Hopefully we may run across good examples of palliative care in the last two episodes this Thursday night and next Thursday night on ABC. Check your local listings. (There I have finally said it. Now I need to cross off "Stop the Presses!") All the episodes are also viewable online and on Itunes.

We may have to do a code count for the show to see how they portray CPR. Any volunteers?

* One commenter dubbed him a "insensivist" I got to remember that one.

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