Patient Case Review: Dr. Shaun Murphy

Shaun Murphy was a blunt force trauma patient in episode 2×18 Trampoline.

Shaun was fired from his residency at St. Bonaventure hospital by Dr. Han in episode 2×17 Breakdown. Shaun didn’t take the news very well, and instead of going to a job interview, he chose to go to a bar for some daytime drinking to take his mind off things.

The only other patron at the bar was Zack Cordell, a young man who got agitated and ended up punching Shaun in the ribs, and also kicked him there while Shaun is already down. Zach then collapsed on the floor for no apparent reason, and Shaun called an ambulance that took both Zack and him to St. Bonaventure hospital.

Zack was admitted to the ER with the following symptoms:

  • Loss of consciousness
  • Laceration with closed head injury (which is curious because he was bleeding from the back of his head when he fell)
  • Possible brain contusion
  • GCS 9 (Glasgow Coma Scale — 15 indicates normal, 3 is deep coma or dead)
  • Possible epidural haematoma (bleed between the brain and the skull)

Shaun himself didn’t appear to have any serious injuries and didn’t complain of any pain. When asked about Zack, he claimed that he found him like that, which we know wasn’t true.

Looking at Zack’s labs, his CBC (complete blood count) was normal, tox screen was clear, no drugs and only trace amounts of alcohol. Shaun accidentally blabbed that Zack’s behaviour and gait were highly suggestive of intoxication, which Claire found suspicious since Shaun had initially said he had found Zack in an unconscious state.

Shaun then suggested that Zack must have a neurological condition and asked Claire to run an EEG and a CT angiogram. (An EEG records brain activity, a CT angiogram is an imaging method to visually display blood flow and blood vessels.)

While they were waiting for tests on Zack, Claire asked Shaun if he was okay, and he said yes. There was no real indication that there was anything wrong with Shaun (beyond the awkward situation with Zack) until he went to the bathroom to look at his own injuries from the beating.

Shaun had a large haematoma on his right ribcage, and he was coughing up blood. Shaun then drew his own blood and asked Carly to analyse it, pretending it was for Claire’s patient. Carly saw through the ruse, but analysed the blood sample anyway. When she asked for the patient’s symptoms, Shaun stated the patient was coughing blood. We can also see that Shaun’s skin was clammy and he was sweating when he talked to Carly.

Carly later sought out Shaun to give him the results of the lab tests on Shaun’s own glood. WBC (white blood count) and PT (prothrombin time) were elevated and haemoglobin was a little low. (The prothrombin time test measures how quickly your blood clots, white blood cell count is usually done to detect inflammation or infection. A haemoglobin test measures how much haemoglobin the red blood cells contain. Shaun’s lab values indicated that there were issues with his blood’s ability to clot and that he was bleeding internally.)

Carly theorized it could be pneumonia or DIC (disseminated intravascular coagulation — a blood clotting disorder), but Shaun interjected it was trauma-induced. Carly then suggested coagulopathy (impaired ability of the blood to clot) was possible, which would make bleeding worse. She suggested to treat the patient with phytonadione as soon as possible and wrote a prescription that she urged Shaun was important to take.

Shaun then sought out Zack, who was being treated for rhabdomyolysis (condition in which damaged skeletal muscle breaks down rapidly). By that point, Shaun was clearly sweating and not doing well. Presumably not having taken any of the phytonadione, Shaun unloaded on Zack about his emotional crisis and losing his job, and while standing near Zack’s bed, realised that Zack had been misdiagnosed and had a Treponema infection that had to be treated immediately. However, before Shaun could communicate this properly, he collapsed next to Zack’s bed.

Shaun was then admitted as a patient with a left haemothorax (accumulation of blood within the pleural cavity) and grade 2 splenic laceration (tear in the spleen) resulting from a rib fracture. Basically, Zack hitting him in the chest had caused a rib to fracture and poke into Shaun’s spleen, which caused internal bleeding in his chest.

The doctors inserted a chest tube to reduce the blood pooling in Shaun’s pleural cavity. He also seems to have been intubated and put on a ventillator at the time. Claire figured out that the trauma must have been a result of Zack beating Shaun up. For a while, as per Dr. Lim, Shaun’s respiratory status was pretty fragile.

Shaun recovered well. When Dr. Andrews came to talk to him, he had an oxygen saturation of 97% and urine output of 200 ccs/h. We can only assume he was discharged without complications, as we next see him back in his apartment, fully recovered.

What Zack actually had instead of rhabdo was an aortic arch aneurism (an outward bulging bubble on a blood vessel) that was in danger of rupturing. He also had tertiary syphilis, also known as Treponema (which Zack misheard as ‘Trampoline’). They repaired the aneurism surgically and Zack was stable afterwards.

Notes from TeeJay:

While I loved the plot of this episode, and how it illustrated that Shaun is, in fact, capable of lying if he has a good reason to, what bothers me is the utter lack of display of pain on Shaun’s part. Thankfully, I can’t speak from personal experience, but anyone I’ve talked to who’s had a broken or even just cracked rib has reported that it’s painfull as hell, to the point where they couldn’t sleep lying down and had to sit up to make it tolerable.

It’s very hard to believe that Shaun was running around with a broken rib like nothing had happened, and never once winced.

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