A Doctor Watches The Night Shift, a Medical TV show, featuring a patient with kidney stones. This episode was originally on Episode 8, Season 3 of the medical …
hi guys Rena Malik urologist and pelvic
surgeon today i'm going to be reacting
to
the tv show the night shift i've
actually never
watched this before and i was told that
season 3 episode 8
has some urologic activity so let's
watch and find out what's going on
pain in the lower right quadrant since
this morning hi i'm dr alexander
dylan ever heard of fop uh yeah the
connective tissue disorder that's me
okay so number one when you come into an
emergency room you usually don't meet
the doctor right away you go through a
triage system
and you get the nurses see you you get
your vitals taken
and depending on how urgent your care is
if
you if they're worried about you being
you know in need of seeing someone right
away then you go right back to the
emergency room but sometimes there can
be a long wait so if you ever go to the
emergency room don't expect
to be seen by a doctor as soon as you
get wheeled in by the paramedics
he looks pretty uncomfortable
okay your pain could be from
appendicitis so i've called first
like how she's examining the left side
of the abdomen for an appy and decided to
give him all the time for the fop i'm
gonna check for that too but we really
don't want to miss an appy
scott this is dylan he has
fop which causes spontaneous familiar
with fop
hey dylan i'm dr clemens hey dylan
presents with a few hours of lower right
quadrant pain
so i wanted a consult for appendicitis
all right john does this hurt here
more like here and all the way to my
back what do you think?
CT? i think you should have checked an
ultrasound and called a urologist it
sounds more like kidney stones
looks like you call that dylan he's
spiking a fever 102.5
okay if it is kidney stones they could
be infected so
let's get a ua and send off a urine culture
all right so a few things here when
someone comes in with abdominal pain
in the emergency room and you're
suspecting either an appendicitis
or kidney stones the first step is to
get a ct
scan of the abdomen so to rule out both
of those things or to rule in either of
those things you would get that imaging
test
so you wouldn't sit there and tell the
patient that we're gonna call a surgical
consult before we got the imaging or
call the urologist before you got the
imaging
also the best test to look for kidney
stones is a ct
scan not an ultrasound secondly
if he's having fevers this can be a
surgical emergency so when someone has
kidney stones that are maybe obstructing
their kidney
that can cause the urine to back up into
the kidney and if that urine is infected
and can't get through to the bladder and
out of the body it can make
even a very healthy person very very
sick
so again she did the right thing by
getting a urinalysis
i'd probably also get what's called a
cbc or a complete
blood count which would also tell you if
the patient has a white blood cell count
or an elevation that is an indication
for infection
it is the kidney stones that are causing
his fever yeah i know
surgery and with fop they could kill him
thank you dr clements
okay so i had to look fop up because
it's a really rare disorder it's called
fibroplasia ossificans progressiva and
so what that is is a rare genetic
disorder
where your connective tissue is replaced
by bone and limits your
movements and so this happens in about
one in two million
people and actually i found one study
that told me
that it is actually three times more
likely for somebody with
fop to get kidney stones than the
worldwide national prevalence of kidney
stones
so also interestingly they do have this
bone growth that can be
triggered by any sort of trauma that's
why they keep saying we have to move him
carefully we have to avoid using
a blood pressure cuff and also going
through surgery
is somewhat of a traumatic experience
and may trigger some bone growth as well
guys this is dr park i've asked him in
for a urology consult
oh great just going to take a look
fascinating i've never seen this real
life
stones causing moderate to severe
hydronephrosis with the infection
he needs surgery right away no excuse me
not doing surgery i've been there done
that i'm not into it okay i think what
dylan is trying to say
is that he would like to avoid the risk
of anesthesia not to mention the
potential permanent calcification of his
urinary tract yeah i for sure don't want
that none of that matters if he gets
septic and dies endoscopic surgery will
minimize bone growth okay there has to
be other options besides surgery i mean
can we at least concentrate on my
opinion you have it
surgery now unless you want to risk
sepsis and death i'm not sure we're
quite there yet
guys first of all urologists are not
like that we're really nice people so
um you know i think what this guy is
trying to say is that if you
do nothing to somebody who's completely
obstructed like this
you will risk getting septic and
potentially death and that's
very very real and so he certainly has
really poor bedside manner
but this is a real issue and needs to be
addressed
rather urgently he also shows the
ultrasound so typically
we don't do ultrasound at the bedside we
have them go to
an ultrasonographer who will take
multiple images of the kidney to
identify
the hydronephrosis which is what he's
showing here or any other abnormalities
in the kidney
and hydronephrosis is swelling of the
kidney which can be due to
an obstruction of the ureter the tube
that drains the kidney that goes down to
the bladder okay there has to be other
options besides surgery i mean can we at
least continue on in my opinion you have
it
surgery now unless you want to risk
sepsis and death i'm not sure we're
quite there yet
what about lithotripsy with antibiotics
we use the sound waves to break up the
kidneys stone and maybe those smaller
pieces pass
on their own well that sounds good to me
we're wasting time this infection's only
getting worse i'm gonna let the or know
that we're covered
wait whoa whoa whoa no okay dr parker
can i speak with you outside
all right one more thing so these guys
are having this big discussion about
options to treat this patient right in
front of the patient
which typically you don't want to
disagree in front of the patient you
would have this discussion
you know separately and then go as a
team as a united front to the patient
because that's
kind of good teamwork secondly i would
never do
as wall or extracorporeal shock wave
lithotripsy in someone who has an
active infection the gold standard and
the treatment of choice is to drain the
system so that you can get the infected
urine
out of the system so you can avoid
getting septic this is
not indicated at all and the fact that
this is coming from someone who's not a
urologist who really has very little
knowledge of urology
shouldn't even be a consideration so
again i think it's good that she's
having them step out to have this
conversation
but i don't really agree with what's
going on
okay he wants lithotripsy why can't we
at least try it you want me to sit here
for a few hours and wait until he's
really unstable and then take him to the
or
if the lithotripsy works maybe he never
even needs you
the patient wants it his pressure's
stable let's try it
fine but his drug will reflect my
recommendation surgery
so one electrocorporeal shockwave
lithotripsy or
as wall does require you to go to sleep
you can't do as well on a patient who's
wide awake so you do need anesthesia to
get that procedure so again i think
they're
perpetuating a myth that's not true this
procedure
is very intense in the sense that you
are basically
in essence getting hit in the blank or
the back side where your kidneys are
multiple times with shockwaves and that
can be quite painful and you can't
tolerate that awake
in this particular patient where trauma
can cause bone growth this is absolutely
not the right treatment
even if he wasn't infected whoa guys
wearing enough layers
this machine used so they are wearing
lead because during this procedure we
use something called fluoroscopy
and fluoroscopy is essentially live
x-rays and so we will take
x-rays to identify where the kidney
stone is
and then target the shock waves to those
x-rays
this machine uses sound waves to help
break up the kidney stone
it's much more likely you'll pass the
pieces than one big stone
in other words i want to pee out some
rocks that's one way of putting it yeah
jordan usually it's like small
dust fragments really really tiny not
rocks
thanks for not going all end of times on
me with that other doctor
yeah he was a bit of a dick
yeah okay here we go
come on what's happening
this thing needs a complete reboot call
the company
tell them to send attack let me know
when it's all fixed okay
oh that blows now what if i get it fixed
it's not surgery right
don't worry we'll get it fixed okay
so i'm not sure i've not used that
particular
shockwave machine i'm not sure if that's
one at all but if you have issues with a
machine typically you will have
someone on site who can help reboot the
machine
call the tech because it may be at a
different time
uh to help you go through the motion to
try and fix it you wouldn't just wait
for necessarily a tech to come in
especially if it was like late in the
evening or at night time
is there anything else that you need
before i try calling again my sanity
back
so every time i'm back in the hospital
it's like constant cycle of shit going
through my head
should have been more careful should
have had more water should have ordered
the salad instead of the five alarm
chili
buddy you gotta give yourself a break
all right you can't second-guess
yourself this much
trust me i have spent half my life doing
it and that way
madness lies all right
i'm gonna see if there's another number
that i can call
son press their pharmaceuticals makes
this machine
well great that question comes up on
jeopardy i'm going to be sure to
remember that
no no no i i think i know somebody might
be able to help us
okay so one you know the quality of life
for these patients is relatively poor
because they have significant pain bone
growth all the time
when you have kidney stones what he's
referring to is there are things that
you can do to prevent
getting kidney stones i've talked a
little bit about kidney stones before
in my reaction to friends as well as my
reaction to seinfeld
but the typically five major things i
tell patients to do
is number one hydrate hydrate hydrate so
drink
lots and lots of water two to three
liters a day number two
you want to avoid lots of red meats
because they can cause you to be in a
state where you would be more likely to
have kidney stones
number three avoid lots of salt number
four
have lots of fruits and vegetables
because that increases your citrate
level and helps you prevent getting
kidney stones
and number five avoid oxalate rich foods
and the most common ones are
spinach and rhubarb if you look at all
the different types of oxalate-rich
foods there's quite a lot so people
will say what am i supposed to eat but i
think what you need to realize is if
you're eating
a lot of one of those items like if you
eat a spinach salad every day
or you eat a lot of nuts those sorts of
things you want to cut back
on but it's impossible to really
eliminate all the oxalate from your diet
so yes there are things you can do to
prevent kidney stones
and more specific things you can do if
you find out what type of kidney stone
you're forming
but in general and someone who's forming
kidney stones and we don't know why
those are the recommendations
oh dylan it's okay i'm right here
okay pressure's dropping hang levophed
pulse is weak
okay he's septic i need you to page
doctor park and tell him to meet us up
your we gotta get these kids out now
so yeah this is what we worry about we
worry about patients getting septic when
they have an
obstructed kidney stone that is again a
surgical
emergency and so when you have this
particular problem you don't get the
kidney stones out you just
drain the system actually trying to take
the kidney stones out or breaking up the
kidney stones
can cause even worse infection so in
this point
you would just try to drain the system
it operated four hours ago he wouldn't
be crashing now hey i'm the one who
could die on the table
dr alexander was listening to my wishes
what happened he septic pressure
strapping we're heading into or now with
the trip she didn't work we didn't get a
chance to try it wasn't repairing time
still an option dylan your
pressure is very low it's getting
dangerous to not operate can we still
try
yes yeah it's frisky but it could work
that's insane no you need surgery we
still have time
if it doesn't work he's all yours
i'll be waiting okay this is crazy
after crazier ideas tonight sometimes
the hail mary works
if you need to trouble this is
absolutely wrong they are putting this
patient at
severe danger of sepsis and death by
delaying surgery and so this is
extremely wrong they should not be
showing this on
network television because it's just 100%
wrong so
how close would you say we were let's
just say it's good you passed that stone
when you did
some high stakes hey jasmine did you
take dylan recovery well wait we're done
that's it
yeah i just kind of feel like we're like
three musketeers there or something for
a second you know
all for one right we make a good team
yeah we do
all right i'll check in on you later
okay okay all right all right
bye guys so on doc hi jocelyn
all right well i'm glad that he passed his
kidney stone and
recovered seemingly very quickly of
course they've
uh they've made this happy ending i
think the one thing that's nice is they
did really kind of highlight
the doctors advocating for their
patients and what they need so there is
obviously patient autonomy and if the
patient doesn't want to proceed with
surgery that is their right and their
choice
however i think the thing i disagree
with is that the other doctors were
disagreeing with the urologist who
knows that definitively this is the
right step to take for this patient
and they the urologist is the one who
would be performing the shockwave
lithotripsy not the emergency room
physician so it would be him who would
say yes i would proceed with the surgery
or not
so in this case what i would do is i
would offer relief of the obstruction
and that would be either with a ureteral
stent
which is a tube that drains from the
kidney into the bladder
and that's an endoscopic procedure as
they mentioned earlier so you look in
with a camera
you pass this little plastic tube that
will then be there temporarily to allow
the urine to drain around the kidney
stone
alternatively you could do what's called
a percutaneous nephrostomy tube
which is a tube that goes directly from
the back into the kidney
using ultrasound guidance and radiology
places this and that allows the urine to
drain
through that tube outside the body and
then alleviates the infection that way
so those are the two options that i
would have offered this patient
if he continued to refuse any sort of
surgical intervention you would just
treat them medically
with antibiotics and hope for the best
however
very likely he would get very septic and
very ill and not be able to recover
because there's no way for that urine to
get out if the kidney
is obstructed so i hope you guys learned
something about kidney stones
and if you have questions if you've had
a kidney stone make sure you comment
below
let people know what that experience is
like i know it's extremely painful
extremely uncomfortable and hopefully
you are doing better getting some care
from a urologist and preventing your
kidney stones in the future
thanks so much for watching and always
remember to take care of yourself
because you're worth it

Leave A Comment

Your email address will not be published
*