An Unusual Case of Pneumonia on ‘The Pitt’: An Emergency Doctor Weighs In

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As “The Pitt” continues its second season, MedPage Today takes a closer look at the series through the perspective of an emergency physician.

Practicing emergency room (ER) doctor Jeremy Faust, MD, editor-in-chief of MedPage Today, reacts to Episode 4’s key cases, from a difficult-to-detect posterior heart attack to an unusual case of aspiration pneumonia. What does the show get right? And how closely does it reflect real-world emergency care?

Click here for more analyses from Season 2 of “The Pitt.”

The following is a transcript of his remarks:

Faust: Hey, it’s Jeremy Faust, editor-in-chief of MedPage Today. We’re back with more analysis of “The Pitt,” Season 2. Here we are in Episode 4. We are going to look at a couple of cases and I’m going to give you my thoughts.

‘The Pitt’ clip: Posterior MI

Faust: OK. So first of all, a little context here. This young doctor had a patient who you can see in the background there, who was given a typical 12-lead EKG, that is the squiggles that measure the electricity of the heart. And the standard 12 leads is usually done. And his looked pretty normal, but this doctor was concerned that it might be a kind of heart attack that wouldn’t show up on a standard 12 lead EKG and that it would actually show up if you moved little stickers to the back of the patient and got a different angle on the heart. One of the most challenging things in emergency medicine is the gulf between an idea and it actually happening. Eventually it gets done, but his inability to actually physically know where the EKG leads should be placed on the patient slows things down, but he actually, to his credit, he sees it through.

And he overcomes an important concept, which is hassle bias. There are many things that we would like to do that we don’t do because it’s a hassle. It slows us down. But in this case, there was that hassle bias. He didn’t know how to do it or needed help, but eventually they got the EKG set up correctly to get those posterior leads. And therefore, when he got the EKG looking at the heart from a different angle, it did diagnose what’s called the posterior MI, a posterior myocardial infarction. So this is a really important lesson that logistics are often a huge issue. And if you just commit to that as a clinician in the ER, you will get those outcomes you want, but it is really difficult when you’re balancing a dozen or a couple dozen patients at a time.

So a heart attack can cause sudden cardiac arrest, heart stopping. And in fact, Vtach [ventricular tachycardia] or Vfib [ventricular fibrillation] would be very common. In this case, a Vtach or Vfib arrest means the patient’s heart stops beating. That’s the bad news. The good news is that’s a shockable rhythm. So defibrillation is going to work in a lot of cases and buy you time.

Oh, by the way, charging while compressing. You notice that he’s charging the device, but here this medical student is actually doing CPR during the charging. That is safe. And actually what’s great about that is you’re still perfusing the body with blood through CPR while the device is charging. So you want to minimize the amount of time where there’s no compressions.

All right. So he does the shock and he says, “Resume compressions.” Does not do a pulse check, does not do a rhythm check, meaning he doesn’t even know if it worked yet. I agree. That’s fantastic. But I like here that they do the shock and they just get back on that chest to minimize that downtime. They can check to see if it worked after a few more seconds.

So after a sudden cardiac arrest in the setting of an acute myocardial infarction or a heart attack, this patient needs to go to the cardiac cath lab right away. And that’s what they’re doing here.

So I love that this happened, but I think also this is an unusual case, but I have to say, I think that it’s one of these things where medical education, this is out there, is so powerful that if you don’t do it on patients who have an unusual EKG finding or who just look sick — this guy did not look well coming in — then you will miss a potentially life-saving intervention that you could administer in the ER.

All right. So next up we have an unusual case of pneumonia that I want to talk through.

‘The Pitt’ clip: Aspiration Pneumonia

Faust: So I think this is a very good inquiry. Aspiration pneumonia is fairly common in older people, especially people with some degree of dementia where there’s just this chronic issue of aspiration. But this is a healthy, relatively young patient. Why should this be happening? Another example, another reason for that would be heavy drinking because then again, it causes essentially that altered mental status that makes it less likely for a patient to manage their own gastric content. And so the question is, why would this relatively young person have that? So a good first question would be, does this person have alcohol use disorder, meaning that they are passed out on the floor and essentially aspirating gastric contents into their lungs?

So Dr. Mel here, Dr. King, she has a theory that this is due to essentially bulimia, that chronic vomiting induced by the patient is what’s caused this.

So I have to admit, I’m not sure I could make that call as an ER doc. I love this idea. I think it’s an important one. I’ve asked patients questions about this in similar circumstances. I’m not sure that I have the clinical ability to look… unless it’s extreme. So maybe in this case it’s extreme. But I like the idea that they’re using this exam as a way to open up a conversation.

So I think this is really interesting. “Can you just give me some medicine?” Yep. They can treat the aspiration pneumonia and that will be the end of it. And you’ve treated the cause of her pneumonia, but have you treated the underlying cause of the pneumonia? And that is in this case, an eating disorder. And hey, this was good continuing medical education for many of us, so I appreciated the way that they handled this one.

So those are some thoughts from some key scenes in Season 2 of Episode 4 of “The Pitt.” We’ll be back next time with more analysis.