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