It’s 4:20 for “The Good Doctor” as it talks about the use of cannabis in Autism and face transplants

This is a part of a weekly series where I watch a new episode of ABC’s “The Good Doctor” (as it comes out in the UK – so I’m a little behind the US sorry!) and review it for it’s realism in portraying autism and medicine. This week’s episode is titled “Faces” – Season 2, Episode 11.

the-good-doctor-season-2-episode-14-shaun-glassman-high

Disclaimer: The featured image and above image is not owned by me and is the property of ABC studios, all rights reserved – it was found on the TV Line website

“Faces” continues the current character arcs present in “The Good Doctor”, not providing anything particularly new to the characters after it but allowing for a bit more development of the current relationships present in the show, namely the friendship of Shaun (Freddie Highmore) and Dr Glassman (Richard Schiff), and the new romantic relationship of Drs Lim (Christina Chang) and Melendez (Nicholas Gonzalez). The latter performs that regular, boring trope in medical drama of “our relationship is going to effect patient care”.

Medically, the show is focused around a kid who requires a facial transplant after a previous accident with a gun lead to destruction of a lot of the tissue on her face. At this point I should not that facial transplant is a pretty specialist and rare procedure. The show did some research into what would be involved in discussing “distraction osteogenesis”, which I hadn’t heard of before (due to it being extremely specialist and so most people won’t have heard of it). However, they ultimately are just using that for technical language and don’t show the realities of this in the end of the episode (according to the Seattle Children’s website you are meant to have the frame that she had on in the earlier parts of the episodes for weeks after the procedure, yet she did not have a frame at all at the end of the episode. Whoops!)

I’m not going to start critiquing the facial surgery much though, because it is EXTREMELY specialist and I have no knowledge in it. Do you know who else would have no knowledge? Most of the surgeons involved in the case. One of the problems with this show is that none of the surgeons appear to have specialities, or if they do then they seem perfectly capable of doing every other speciality as well. Dr Andrews is a plastic surgeon, so may have knowledge of this EXTREMELY specialist technique. Maybe. But Dr Melendez is mainly in cardiothoracic and Dr Lim is in trauma. Yet they seem able to do the most complicated techniques that belong so far away from their specialities that who knows how they learnt it. This saves your budget for hiring actors, but is really unrealistic. Not only do they not really have any place being in this operation (yet alone leading in removing the donor face), but their juniors have no place either really.

I have reasons from this episode to question the business strategy of this hospital (ex. having all of your staff line up in a corridor before this procedure, having all of your surgical staff cancel their surgeries for this one procedure), but when you have doctors able to fulfil the role of all of these specialities so well then maybe this isn’t actually a problem. One of the things I have noticed is that they save a lot of money on not needing to hire anaesthetists. In this episode the surgeons are transporting Karen (the girl who unfortunately died earlier in the episode) to the operating theatre with only three staff members while she is still on a ventilator. She is not connected to any of the regulatory drugs that she would require for ensuring that her vitals stay in a set range, which is odd. Overall, from having been involved in a few transports of patients in similar situations, a well trained intensive care doctor should be present to specifically look after all of the equipment and make sure that nothing goes wrong. They should be staying with the head to make sure that the airway is stable throughout transport. Therefore, this situation doesn’t make sense unless the doctors are so well trained that they can belong in every speciality. Later on in the episode, Dr Reznick (Fiona Gubelmann) is the one to turn off the ventilator after she has just been involved in the surgery for the facial transplant. While efficient, she should be no where near that machine and the anaesthetist should be in control.

However, it does the general medicine right. When Karen is brought in they talk about her GCS being 5. GCS is the Glasgow Coma Scale and is used to measure assess conscious level (importantly letting you know if someone would be able to support their own airway or not). Normal conscious level is 15. If it is below 7 then you need to be really worried about a person’s ability to control their airway. They say she has a GCS of 5 with decorticate posturing. Given how the scoring works this means that she has no verbal response and no eye opening, which at the time she doesn’t. So good job for getting that right! (If you want to learn about the scoring of GCS, look at this image (https://sketchymedicine.com/wp-content/uploads/2012/09/GCS.jpg). I used it throughout medical school to keep it in my head).

They go on to say that her blood pressure measurement between her two arms is different and the doctors go to the conclusion that she likely has an aortic dissection, which is a nifty sign that you are taught about at medical school. I was told to feel for pulses on both sides as a part of your examination and feel for asymmetrical pulses. So this is fair. Furthermore when in the operating theatre they are trying to decide what the priority is for treatment and go with the dissection over the possibility of a “brain bleed” (that they can’t see on CT anyway – given the history she could have an extradural haemorrhage, but anywho) and they go for the dissection first. This is sensible. In managing trauma there is an ABCDE approach that is rammed into everyones head that shows the priorities that should be managed in what order (based on how quickly you’ll die without each thing). A is for airway, and needs to be managed first. B is for breathing. C is for circulation (which an aortic dissection would fall under as a cardiac emergency). D is for disability, but basically means brain stuff while E stands for environment (and is anything else that doesn’t fall into the other categories). Therefore, an aortic dissection would be the priority in this scenario (if it is the type that requires surgical management, which we’ll just let them assume that it is for the sake of this case).

But let’s talk their autism topic of the day – ASD and the use of cannabinoids. Shaun jumps to trying the marijuana a bit too quickly for his character and has to be reminded about research studies and their validity. But I’m fine with that. I can see this situation happening with Shaun possibly thinking about this for a long time and responding a bit abruptly to it due to this. The potential use of cannabinoids in a range of different conditions is becoming more and more popular to discuss as more cases of their ‘efficacy’ as being produced. Let’s have a look through the evidence for cannabinoids in autism. We come into the common problem while looking for this, there is not much good research looking at interventions in autism. There is one paper that is published in Nature’s Scientific Reports journal titled “Real life Experience of Medical Cannabis Treatment in Autism: Analysis of Safety and Efficacy” published in 2019 that overall reports positive effects of reducing certain symptoms with few adverse effects. However, this is a non-blind probably best described as cross-sectional study where they take a section of their population, find the ones with ASD who also use marijuana and follow them up at certain points. This would be a cohort study if they had a second population that was not receiving the treatment, but this wasn’t practical in their case. I feel that there would be something to say in trying a randomised control trial in this case, where you give one group cannabinoids and the other a placebo. But ethically this holds issues and so would be difficult to support at this point when safety is questionable. However, due to their comparator for efficacy being opinion of the people involved in the person’s life, this introduces a fair amount of potential for bias and makes me less trusting of the study.

To add to my concern about this study, they also lose a lot of patients during the follow up phase losing 69 participants in 1 month, and a further 26 by 6 months. This gives a total of 95 people lost to follow up (51%). This is poor and makes me doubt the validity of the study. To further make the results of this difficult to interpret, a lot of the participants are on a range of different medications including antipsychotics, antiepileptics, hypnotics and sedatives and antidepressants. 67 of the final 93 patients reported taking other medications at the same time (72%). This makes things difficult to see as cannabinoids have effects on the reception of other drugs, therefore, positive effects may not be directly from the cannabinoids. The patients are on different doses, so that isn’t standardised (it isn’t associated with weight either, so there isn’t a standard pattern to go with). Furthermore, patients have other comorbidities. The final view is extremely murky where there are so many confounding variables that you cannot really interpret this very well into whether the marujana actually helped or not.

To bring some positive things about this study, they do note their biases. They note that a reaction to a ‘miracle effect’ could not be excluded, and that there may be a ‘self-selection bias’ from the population as people who are choosing to seek this treatment. Also they talk about a range of different positive effects and side effects. They also find out why 23 patients who discontinued treatment stopped (two-thirds due to there being no clinical effect, with the other third being due to side effects).

The results that they show report improvements in restlessness, rage attacks, agitation, sleep problems, seizures, anxiety, tics, constipation, digestive problems and depression in a majority of cases. It was shown to either have no change or worsen speech impairment, cognitive impairment and incontinence in the majority of cases.  The most relevant ones of these that jump out to me is the effect on seizures, where 12 people reported that they stopped or they noticed improvement, with none reporting no change or deterioration. They could be underreporting or not recognising seizures, but this is a bit more objective than a lot of the categories which are subjective. What constitutes a ‘rage attack’? How are they defining if restlessness is improving or not? What about agitation? These are subjective areas. But events like seizures pique my interest a little more – but that is the focus of another study. It goes on to do a bit of statistical analysis around a few areas, which show results that I think you would see from this ‘miracle effect’ that they talked about in their discussion (going from no one thinking that a person’s concentration was good or very good before taking the drug, to a lot of people thinking it was miraculous – without formal assessment techniques being used this makes me sceptical).

Overall, I don’t think this study is particularly good and there is at least nothing in there that makes me think that cannabis should be used in autism (but maybe in epilepsy, but again, the study isn’t great so I don’t trust that). I would think that more studies should be done with better controlled conditions so you can actually see a link between the areas, but that might be difficult to achieve at this time.

With all alternative management options for autism, I think that there is a degree where research can help and a degree where you need to take it on personal experience. Studies are not always right, and some things may have benefits that do not have proof in scientific literature (as someone who uses tinted lenses, which are generally proven to not be helpful in literature but lead to me improving my exam marks by 30%, I can admit that fully). But it is important to look at the risks for each options and the use of cannabinoids comes with risks that you need to think about before using them (let alone legal elements dependent on which country you are in). All I can say is from this article, which is the best one I could find from a brief search, there is nothing in there that would make me think that taking medical marijuana would help.

But back to “The Good Doctor”. Overall, Shaun and Glassy have a lot of fun on their doped up journey across the state, which is nice. I love the Uber driver (Mo Gaffney) and would like her to be my eternal companion throughout life in any car drive as she seems great. I was watching the episode and thinking that their representation of autism was pretty good, but then there is a line at the end where Shaun starts to say that “guilt must be a bad thing because X”, which (at least in my interpretation) implies that Shaun doesn’t feel guilt. Autism and empathy is a subject for another post (as this one is getting pretty long) but I don’t believe this is good portrayal or realistic. But let’s save that one.

My last note is do these people know where it is appropriate to have sensitive conversations? The poor mother of the girl who died had doctors that she didn’t know talking to her about very sensitive conversations in rooms with other people, the chapel, corridors and other random places. Generally, good practice in discussing difficult conversations is to talk to the person in a quiet room away from other people to give them more support and allow them some privacy. She did not have much privacy during this episode when dealing with an awful situation, so that’s pretty sad (considering that you can afford magical glowing whiteboards, you’d think you can afford a room to talk to someone in). Also nurses would be way more involved than they are (as nurses as brilliant and bring a lot to the patient-healthcare professional relationship) so the absence of them is unrealistic.

That brings us to it. Overall, this episode was a needed bit of continuation of the general narrative without any escalation of drama after a few episodes where the drama level has been building. It brings in some good medical elements and a good discussion point regarding autism and cannabinoid use. However, it still struggles to run a hospital in a realistic manner and potentially undermines it’s representation just at the last minute.

Rating for medical accuracy: C

Rating for autism representation: B

References:

ABC Studios. The Good Doctor. Season 2, Episode 14 “Faces”.

Schneider, L. Mechoulam, R. Saban, N. Meiri, G. Novack, V. (2019). Real life experience of medical cannabis treatment in autism: analysis of safety and efficacy. Scientific Reports. 9 (200). 1-7.

Seattle Childrens (Last accessed: 20th February 2019). Distraction Osteogenesis. (URL: https://www.seattlechildrens.org/clinics/craniofacial/services/distraction/)

Sketchy Medicine (Last accessed: 20th February 2019). Glasgow Coma Scale. (URL: https://sketchymedicine.com/wp-content/uploads/2012/09/GCS.jpg)

Schwartz, R. (2019). The Good Doctor Recap: Ridin’ High – Plus a Miraculous Face Transplant. (URL: https://tvline.com/2019/02/04/the-good-doctor-recap-season-2-episode-14-face-transplant/). Last accessed: 20th February 2019.

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