LA Times Health - The Unreal World
|LA Times Health - The Unreal World
By Dr. Marc Siegel
Caesarean section, in theory and in 'Practice'
In the 'Grey's Anatomy' spinoff, Addison Montgomery performs an emergency operation without the typical resources for surgery.
"Private Practice," series premiereSept. 26, ABC, 9 p.m.
The premise: Dr. Addison Montgomery (Kate Walsh) is a top obstetric and neonatal surgeon who has just joined a boutique practice, the Oceanside Wellness Center in Santa Monica. Her first case is a young woman in labor who develops a compressed umbilical cord, causing fetal distress. Pete Wilder (Tim Daly), an alternative medicine expert at the center, notices that the mother-to-be is having difficulty breathing. She develops jugular venous distention (a sign of acute heart failure in which blood backs up into the lungs and engorges the veins) and a rapid heart rate.
As the patient becomes more lethargic, Pete implores Addison to perform an emergency caesarean section. Addison hesitates because the clinic doesn't have general anesthesia, blood for transfusions or sterile drapes. It also doesn't have the ability to treat the patient's pain properly because, Addison says, epidural anesthesia wouldn't act quickly enough. Still, Addison and Pete conclude that they don't have "the 10 or 20 minutes" it would take for an ambulance to arrive. Concerned that the patient will "feel every slice," Pete offers an alternative treatment to traditional anesthesia -- using needles, combined with injected Lidocaine, to block pain receptors in the body.
As Addison is about to operate, the patient's father announces that the patient's mother died giving birth to her years before. During the high-risk operation, the patient develops a heart arrhythmia (ventricular tachycardia) and is defibrillated (shocked with electricity) back into normal rhythm. The baby survives, and the mother recovers quickly.
The medical questions: Can fetal distress, caused by a cord compression, lead to life- threatening heart failure in a pregnant woman? Is the tendency to suffer heart failure in the later stages of pregnancy a genetic condition, and is it rapidly reversible following a successful C-section? Would epidural anesthesia, a standard choice for C-sections, be too delayed to be effective in this case, as Addison maintains? Are the use of needles and local anesthetic, administered by a holistic healer, a reasonable alternative to block pain?
The reality: Compression of the umbilical cord may well cause fetal distress, necessitating an emergency C-section. It can also cause rapidly progressive preeclampsia (high blood pressure, protein in the urine and fluid retention) in the mother. Preeclampsia in turn can cause pulmonary edema (severe congestive heart failure), as Addison's patient experiences, according to a 2003 study in the journal Obstetrics and Gynecology. Preeclampsia, which is multi-factorial but does run in families, is almost always cured by delivery of the baby. Thus, Addison's patient's rapid recovery after surgery is realistic.
The acupuncture-type anesthesia employed by Wilder involves inserting needles directly into nerves and stimulating them with electric shocks until they can no longer conduct impulses, which theoretically produces local anesthesia. Though this experimental technique is used in China, where Pete studied, it is not intended for emergencies and almost always involves the liberal use of sedatives and painkillers.
"It looks like voodoo to me," says Dr. Michel Dubois, professor of anesthesiology and director of education and research at the NYU Pain Program.
Dubois further explains that injected Lidocaine can sometimes "go systemic," and cause seizures or cardiac arrest. So it should only be used when the patient is being carefully monitored, which is not possible in the clinic.
Although epidural anesthesia (in which a drug is injected by catheter into the space around the spinal column) generally works within 10 to 20 minutes, its onset can be hastened to 5 to 10 minutes by injecting a numbing agent directly into the cerebrospinal fluid, Dubois says.
However, according to Dubois, since the patient is undergoing surgery while suffering from congestive heart failure, "the need to maintain an airway and ensure adequate respiration no matter what kind of anesthesia is used is crucial." But the clinic doesn't appear to be outfitted with breathing tubes or respirators, so epidural anesthesia would have been Addison's best and safest choice, though still quite risky.
Dr. Marc Siegel is an internist and an associate professor of medicine at New York University's School of Medicine. He is also the author of "False Alarm: The Truth About the Epidemic of Fear." In The Unreal World, he explains the medical facts behind the media fiction. He can be reached at email@example.com.
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