We're back to our regular installments of "Lesson Learned From The Pitt", now covering episode 7 as we slowly catch up to the releases.
Spoilers, oh boy are there spoilers. Here's a link to a quick reference guide for the TL;DR crowd.
And a trigger warning for allegations of CSA.
To me, episode 7 is where the Grey's Anatomy-esque drama really starts to kick off. We've been seeing signs of various teakettles slowly reaching their boiling points across the first third of the season, and the first to boil over is — unsurprisingly — the man who's been crushed by a multiple days' worth of critical patients in a single morning, while juggling patient satisfaction concerns, while dealing with increasingly-frequent PTSD flashbacks. When Whitaker eats lunch at a desk, he tells him off for not eating in the lounge (and for spilling a boatload of crumbs on the workstation, get that boy a SLP evaluation!) while also implying that it's too busy for the student to be eating. When Dr. Mohan orders additional labs on a patient he'd medically cleared for psych evaluation (premature closure after not taking an actual history, nice!) he berates her rather than appreciate her ability to tease out highly relevant and plan-changing information in the history, with Dr. Collins being caught in the crossfire for supporting her junior. But Dr. Robby's real explosion is yet to come, so let's turn to someone else who crosses the Rubicon this episode.
Dr. Mohan isn't the only one who's a bloodhound on tiny details — we've been seeing Dr. Santos investigate the mystery of the hard-to-open benzo vial in the background, and in this episode her vigilantism will continue. Previously, a trauma patient (s/p mechanical fall from ladder) had needed intubation and a chest tube; Dr. Santos had noticed gynecomastia (enlarged breast tissue) which could be a sign of an underlying condition like alcoholism, and decides this needs to be investigated further in the ED before she sees any new patients. On questioning the wife, we find out that she's been doping her husband's coffee with progesterone. Why? Because she suspects her husband of molesting their daughter, and wanted to "kill his libido".
Dr. Santos appropriately brings this to the attention of Dr. Robby (hey, she does know how to escalate to the right person!), knowing that they are mandated reporters in this state. However, Dr. Robby and social worker Kiara (both heavily overworked by this point) proceed to make one of the biggest fumbles of the show so far — telling her that they cannot make a report without "proof" and that this is all speculation. That they "can't do anything" unless the daughter comes forward. They are right in that they need to report the wife for poisoning her husband, which would at least be a first step (if suboptimal) in getting an authority involved in the situation.
Detective Santos goes around her attending and tries speaking to the daughter after a clumsy (and failed) attempt at building rapport. The daughter denies everything and is obviously uncomfortable with this conversation. And so our brilliant intern decides to take matters into her own hands, by entering the room of an intubated and vulnerable patient, confronting him, and threatening him ("blink once if you want me to let you die"). Whether Mr. Dunn is an abuser or not (at this point we only have allegations, and in America we believe in "innocent before proven guilty"), for a physician to behave in this manner is beyond the pale. Our ethical duty is to provide unbiased and professional care to everyone regardless of their standing, and certainly not to threaten a patient with prison rape or even murder (imagine being an innocent man or woman and having your doctor come into the room accusing you of heinous crimes, while you're powerless to do anything if they decide to disconnect your ventilator). Taken in context with Dr. Santos's pattern of reckless behavior and disregard for others, I can only hope that the trauma bay is recorded (like ours) and this leads to disciplinary action.
What should Dr. Santos have done?
She's absolutely right about being a mandated reporter. In both PA and NY law, most professions that come into contact with vulnerable populations (such as children) fall into that category. The threshold to make a report is not "we need proof", it's "reasonable cause to suspect". PA law clearly states that a specific disclosure by a third party to a mandated reporter that an identifiable child is the victim of child abuse meets that standard; that the accuser is the alleged victim's other parent heightens the need to make a report. NY law, which is what matters for us, specifies that a report should be made "when they have reasonable cause to suspect that a child coming before them in their professional or official capacity is an abused or maltreated child, or when they have reasonable cause to suspect that a child is an abused or maltreated child where the parent, guardian, custodian or other person legally responsible for such child comes before them in their professional or official capacity and states from personal knowledge facts, conditions or circumstances which, if correct, would render the child an abused or maltreated child". #Believe when it comes to the threshold for making a report. Let the police do the investigation.
Both PA and NY have hotlines for mandated reporters to make reports. In New York, we can call the State Central Register Mandated Reporter hotline directly at (800) 635-1522. Reports can also be made anonymously at (800) 342-3720. For mandatory reports, a written report must be made and sent within 48 hours of the call. Reports are confidential. One does not need the approval of a supervisor to make reports. One cannot be held liable for good faith reports. One is theoretically shielded from backlash/retributions from making reports. Not reporting when you have reasonable suspicion is a thoughtcrime for which one can be hit with a Class A misdemeanor. PA offers similar protections as NY, and even harsher penalties for failure to report (up to a 2nd degree felony).
It's hard for someone, especially a transitional year intern, to gainsay the attending. But would you be willing to commit a crime for the attending? We already know Dr. Santos is willing to commit crimes for herself :D
Other little lessons from episode 7:
To quote Dr. Collins, "leave your baggage at the door like everyone else". An impaired physician, nurse, paramedic, etc. is a terrible thing for a patient.
Dr. King demonstrated an excellent conversational approach to patients with autism spectrum disorder. She minimized distractions by closing the doors, shutting off alarms, and turning down the lights. She invited the patient to speak about their concerns and verbalized empathic statements. She was patient with her clarifications. She took time to explain the diagnosis at the patient's level of understanding. Note that these are things that can be done with all patients to improve their experience.
During a cardiac arrest code, the team attempts double sequential defibrillation for refractory v-fib. The 1st shock theoretically potentiates the effect of the 2nd. Unfortunately, meta-analyses have found no overall benefit to v-fib termination (or survival), and it is not recommended by the AHA for routine use.
For that same code, the team activates their ECMO team. Extra-Corporeal Membrane Oxygenation is a technology that oxygenates a patient's blood outside the body and then returns it, analogous to hemodialysis. Broadly-speaking, it is indicated for acute cardiac or pulmonary failure that is potentially reversible, has failed conventional treatment, and carries a high risk of death. In-hospital cardiac arrest is an example of a condition that has a decent chance (~30%) of survival with ECMO.
References:
https://www.pa.gov/content/dam/copapwp-pagov/en/dhs/documents/keepkidssafe/clearances/documents/FAQ_Mandated%20Reporter.pdf
https://www.nyc.gov/site/acs/child-welfare/mandated-reporters.page
https://www.nysmandatedreporter.org/SocialServiceLaw.aspx|
https://www.ncbi.nlm.nih.gov/books/NBK544231/
https://www.ahajournals.org/doi/10.1161/res.135.suppl_1.Mo035
https://pmc.ncbi.nlm.nih.gov/articles/PMC7867121/