Biology Concepts explained in this episode:
- Why is there a lot of bleeding from the head?
- What is epidural hematoma?
- What is Treponema or tertiary syphilis?
How the problem was first identified:
The show starts with Dr. Shaun Murphy in a bar trying to strike a conversation with a man. The man appearing offended with Murphy’s question as to why he was getting drunk early in the morning, stood up, shoved, and punched Murphy.
Murphy fought back which made the man fell on his head causing him to bleed a lot on the floor.
Why was there a lot of bleeding from the head?
Our head houses tons of blood vessels. It protects the brain, which as we all know, is a very important organ.
While the brain makes up about only 2% of the body weight, 20% of the blood that leaves the heart goes to the brain because there are tons of processes going on inside the brain consuming a lot of oxygen and nutrients. Plus, of course, we have the other parts of the head such as our eyes, the different muscles of the face, and so much more.
This is the reason why there was so much bleeding on that guy’s head. Considering the number of blood vessels we have on the head, even a minor cut may cause a lot of bleeding.
What is Epidural Hematoma?
Initial Findings: As the 31-year-old male patient was being rushed to the emergency room, he was presented as someone with a laceration with a closed head injury and possible brain concussion. Dr. Murphy’s diagnosis was Epidural Hematoma.
Why did he say so?
Let’s take a quick look at the BRAIN:
The brain is surrounded by 3 layers of membrane:
- The Pia Mater (inner membrane) – fused directly to the brain
- Arachnoid mater (middle layer). This layer is loosely connected to the pia mater by connective tissues. In between it and the dura mater are blood vessels and a space called the subarachnoid space. This space is where the cerebral spinal fluid flows.
- Dura Mater (Outer layer) fused directly to the arachnoid and the periosteum of the skull.
The dura mater is the thick outer layer normally attached directly to the inside of the skull. The term “dura” originated from Latin meaning tough or strong, durable.
Normally, there is no space between the dura mater and the skull, but a traumatic brain injury, like the man hitting his head on the floor in the opening scene, can disrupt some of the vessels causing them to break and bleed into the area.
If the bleeding occurs above the dura mater, it’s referred to as epidural (epi = above) hematoma; whereas if it occurs below the dura mater, we refer to it as subdural (sub = below) hematoma.
Laboratory results indicated the patient showed no signs of intoxication. Dr. Murphy noted that the man had an erratic gait and behavior. He said that he could have some neurologic issues and suggested running an EEG and CT angiogram on him.
Realizing an incorrect diagnosis:
In the next scene, as Dr. Murphy was conversing with the patient in his room, he started gazing and looking around (as he always does as if trying to figure something out).
He realized that the patient was diagnosed with the incorrect condition. Just before he passed out, he said the patient had a “trampoline” and that he had to be treated immediately.
Dr. Murphy’s colleagues, specifically Dr. Claire Browne figured what Dr. Murphy was trying to point that the patient actually had treponema, which they think the patient may have misheard as “trampoline”.
What is Tertiary syphilis or Treponema?
Syphilis is a sexually transmitted disease caused by the bacteria Treponema pallidum or treponema for short.
There are four stages that patients go through when they contract syphilis:
- Primary syphilis
- Secondary syphilis
- Latent
- Tertiary syphilis
The effects can range from skin ulcers on the genitals (present in primary syphilis) to affecting a whole host of other systems of the body. An aortic arch aneurysm is one of the complications of tertiary syphilis.
Reviewing the circulatory path of the blood, we know that the right side of the heart gets the deoxygenated blood from the rest of the body. It sends the blood to the lungs to pick up some oxygen and enters the left side of the heart.
As blood leaves the left side of the heart, it passes through the aorta (that arches over) and then goes to the rest of the body.
The aorta is the main blood vessel coming off the heart. You can just imagine that if anything happens to it could mean some serious issues going on inside our body.
Dr. Murphy’s colleagues found that the patient had an “aortic aneurysm with signs of impending rupture. The evidence of this was a pulsatile mass in the patient’s neck. Plus his erratic gait and behavior explained tertiary syphilis or treponema.”
How did aortic aneurysm develop from tertiary syphilis?
In the case of tertiary syphilis, bacteria get into the wall of the aorta. The body dives into an immune response causing some inflammation to happen. All these events can lead to the death of the elastic tissue (necrosis).
When that happens, a bulge forms on the wall of the aorta. If the bulge gets big enough and ruptures, the blood escapes from the aorta and pool down into the body.
Depending on the size of the rupture, it can lead to shock and eventually death within minutes to hours if the problem isn’t fixed.
This explains why Dr. Murphy, right after he woke up, was urgently asking if the patient was already being treated for the right condition. Fortunately, Dr. Browne already figured it out and immediately did the operation on the patient to repair the aorta.
Summary
- Often times, when we injure any part of the head, there is usually an alarming amount of blood due to the fact that our head houses tons of blood vessels.
- Epidural hematoma is bleeding that occurs above the dura mater.
- Tertiary syphilis or treponema is the late stage of the disease where the bacteria may have affected several body systems. The bacteria that causes all of these is called Treponema pallidum or treponema for short.