Wilson’s disease on television

Michelle (k/a Mikhaila) Muscat MD, MRCS(Ed), MSc

University of Malta,Tal-Qroqq, Msida, Malta (Winter 2016)

The television series Scrubs, created by Bill Lawrence, is a popular medical comedy that follows the hospital adventures of the main protagonist Dr. John “J.D.” Dorian (Zach Braff) as well as other hospital staff employed at Sacred Heart. The TV series spans numerous seasons and hence features several episodes introducing medical conditions.

In Season 7, episode 11, “My Princess” (2008), two medical students play a game in which they give each other clinical clues and have to guess the correct diagnosis. One medical student asks the other to name the condition in which there is “a genetic defect that presents with anemia and causes copper build-up in the liver and other organs and destroys them”. The other student immediately replies, “Wilson’s disease!” J.D also happens to be in the room at the time but is busy with other matters and apparently not paying attention to the students’ conversation.

Wilson’s disease, the students’ diagnostic choice, is a rare inherited condition in which copper accumulates in vital organs such as the liver and brain. It presents with neuropsychiatric and hepatic signs and symptoms, sometimes with hemolytic anemia and deranged coagulation in the setting of liver failure. About some 95% of patients have a characteristic brownish-yellow ring in the eye called the Kayser-Fleischer ring at the junction of the sclera and the cornea. To make a diagnosis of this rare disease requires good clinical acumen, requesting and interpreting the right tests, and above all, carefully examining the patient. These criteria are illustrated in the Scrubs episode by two parallel stories, both of which depend on the finding of a “golden ring” for a favorable outcome.

Later that day at home, another hospital physician, Dr. Cox (John McGinley), begins to tell his son a bedtime story about a nurse, a surgeon, a doctor, and a village idiot (the latter choice apparently in keeping with Dr. Cox’s view of J.D., as stated throughout the show). Dr. Cox’s wife believes that because their son is only four years old, hospital stories are not appropriate. Dr. Cox immediately obliges and changes the story to that of a two-headed witch, a princess, and a village idiot. The two parallel stories are then seen to take place, the one in the hospital and the other in a fictitious village, one literal and one metaphorical, but both ultimately telling the same tale.

In the fictitious setting, the village idiot is sent by the princess to rescue her maiden, who is being held captive by a monster. He finds the monster, but is so frightened that he passes out. A valiant prince who is in love with the princess comes to help, and is followed by a two-headed witch. The village idiot offers the princess a ride on his donkey to make their way to the magic potion shop, as suggested by the witch. Once there, they eventually decide they must send out a messenger pigeon to call on the expertise of the bravest of knights. A knight confronts the monster but to no avail. After the brave knight is sent flying out through the window, he suggests that the only way to save the maiden is to go to the forbidden forest and find a golden ring. He ultimately finds it and frees the maiden. The messenger pigeon symbolizes paging the more senior doctor while the golden ring represents making the diagnosis by finding the Kayser-Fleischer ring.

In the hospital setting, the junior resident has ordered a variety of tests but is still floundering. The patient is said to have kidney malfunction, clotting problems, and internal bleeding. The clinical clues are relatively few and non-specific. Hepatitis tests have come back negative. More laboratory results are brought over by Carla (Judy Reyes), but there is still no diagnosis. Nobody seems to have noticed anything significant about the patient’s eyes. Finally, J.D. looks at the patient’s eyes with an ophthalmoscope and finds the “golden ring”— the Kayser Fleischer ring, and the diagnosis is made. At the end of the episode when Dr. Cox leaves his son’s room, his wife asks him if the girl has received a liver transplant on time.

Dr Michelle (k/a Mikhaila) Muscat is a doctor in chemical pathology. She is a member of the Royal College of Surgeons of Edinburgh, and obtained associateship of the Royal College of Pathologists. After completing an MSc with distinction, she is currently completing her PhD. She harbors a strong interest in clinical biochemistry, a laboratory science at the heart of modern medicine. Outside the labs she has a passion for poetry, languages, swimming, acting & aspects of Japanese culture.

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