The Pitt 1x5

1. You sent labs?

2. No indication.

3. Normal vitals, normal neuro exam.

4. Dude just dropped—no warning.

5. - What's open? - Trauma 1.

6. Grab Langdon or whoever else is avail.

7. What have we got?

8. Seizure in chairs.

9. Thank you.

10. How is it out there?

11. Chaos. We're never gonna catch up.

12. Lorazepam's on board.

13. Okay, draw up another 4.

14. Yeah, no history.

15. Doesn't look like he's been here before.

16. Satting low 90s on 5 liters.

17. Another 4 milligrams.

18. I can't get the top off.

19. It's—it's just the plastic, not the metal.

20. No, I know. I know, I know.

21. Here, give it to me.

22. No, I got it.

23. Okay.

24. Ordering CBC, CMP,

25. and a straight cath for a urine tox.

26. All right. Pushing the second 4.

27. If this doesn't work, we need to prep Keppra.

28. No, we'll give more lorazepam.

29. It's already ordered.

30. He's already had 8 milligrams.

31. He'll stop breathing. - Then we'll intubate.

32. Sometimes a patient needs a little more.

33. - How long has he been seizing? - About four minutes ago.

34. He started seizing in chairs.

35. He's already had 8 of lorazepam.

36. I want to move on to Keppra, but Dr. Langdon disagrees.

37. I just want us to try another 2 milligrams before moving on.

38. Dr. Langdon's patient, Dr. Langdon's call.

39. Dennis Whitaker, meet Bob Chazen,

40. a 53-year-old cyclist who injured his leg

41. about ten days ago on a trip to Utah.

42. I was in Moab, coming downhill fast,

43. and jammed my pedal into my leg.

44. Ooh, ouch.

45. That's some gnarly road rash.

46. White Rim Trail.

47. I've been putting Neosporin on it a couple times a day,

48. but now it hurts to walk.

49. What do you see, Whitaker?

50. Um, outside of the wound looks cellulitic.

51. What's that?

52. It's a bacterial infection.

53. We'll need to get you on oral antibiotics.

54. Figured.

55. What about the center of the wound?

56. Uh, it's a simple hematoma.

57. Which you can now debride.

58. Whitaker will take off the dead skin covering the blister

59. to help it heal better.

60. I'll be right back.

61. Yeah, uh, quick question.

62. Get some Iris scissors, toothed forceps, sterile gauze.

63. No, it's just, um—

64. Blister guy? Really?

65. Mr. Chazen was the next patient on deck.

66. I know I screwed up earlier.

67. You didn't screw up.

68. The patient died.

69. It happens.

70. Just don't amputate Mr. Chazen's leg.

71. Okay. Hey.

72. Another 2 of lorazepam.

73. - For a total of 10. - I'm well aware.

74. He's still seizing.

75. Call respiratory.

76. I'm setting up an intubation tray.

77. Which we won't need.

78. Dr. Santos, what is the definition

79. of status epilepticus?

80. A seizure lasting more than five minutes

81. or at least two seizures

82. without full recovery in between.

83. Excellent.

84. Seizure activity has stopped.

85. Also excellent.

86. Spontaneous breathing, good tidal volume.

87. Sats up to 98.

88. Welcome back, Mr. Marino.

89. Now we can do a Keppra load slowly and safely.

90. Nice work, Dr. Langdon.

91. I will be at Central if you need me.

92. This must have been a bad vial.

93. 8 milligrams should have worked.

94. According to your textbook of emergency medicine.

95. But sometimes they need a little bit more.

96. You'll learn that with time.

97. Well, why couldn't I open the vial?

98. Because you're an intern

99. who also needs to learn to trust her senior resident,

100. especially in front of an attending.

101. Now check his labs,

102. babysit him until he goes to CT,

103. and get some blankets on these side rails

104. as a seizure precaution.

105. - Is this gonna hurt? - Oh, no.

106. Skin's dead. You won't feel a thing.

107. First time in Moab?

108. No, no.

109. I belong to a club, Gears and Beers.

110. We started riding to Frick Park during the pandemic—

111. you know, just something to do to get out of the house.

112. But we all stuck with it, and now we go on biking trips.

113. Huh.

114. Ahh! Ahh!

115. Oh! Whoa, oh!

116. Help! Do something, man!

117. - Um— - Oh!

118. - Uh— - Dude!

119. Oh, ow!

120. I need a little help here!

121. Jesus!

122. Hey. What's up?

123. Arterial pumper under a blood blister.

124. - Let's see. - Oh.

125. - Jesus! - Oh, God.

126. Noob.

127. Hi, I'm Dr. King. Um, we can fix this.

128. - Did you cut an artery? - No, no.

129. I-I punctured the top of the blood blister,

130. but there was an artery hiding under there.

131. Hiding?

132. Like—like you didn't know it was there?

133. Don't you have to know basic anatomy to become a doctor?

134. He's a student doctor.

135. What the fuck?

136. Student?

137. Oh, hell, no. No, no, no.

138. Can—can you help me?

139. Can you fix it? - Oh, absolutely.

140. First, we are going to put this BP cuff on

141. to stop the bleeding.

142. A little forward.

143. There we go.

144. All right, you can let go.

145. - Yeah? - Mm-hmm.

146. - Thank God. - Oh, thank God.

147. All right, Whitaker, 10 ccs of 1% lidocaine with epi.

148. Yep.

149. Uh, the shot is gonna numb the area

150. and also constrict any blood vessels

151. so that we can put a little stitch in there.

152. What happened in here?

153. Uh, hidden laceration of an arteriole under the vesicle.

154. Uh, bleeding stopped at 180 on the BP cuff,

155. and we are now injecting lidocaine with epi.

156. Thank you, Dr. King.

157. Let's set up a suture tray with 3-0 nylon.

158. Okay. A pinprick and some burning—

159. Doc, Doc, can you step in here, please?

160. You got this, Whitaker.

161. That ambulance chase is on live TV.

162. - What channel? - Every channel.

163. Ooh, what do you think the over-under

164. on clipped cars should be?

165. 15. - Mm!

166. Come on.

167. Can I put it on the TVs in the waiting room?

168. Fine by me.

169. I just hope wherever it ends up,

170. it's out of our catchment zone.

171. Got a second?

172. It's never a second, but shoot.

173. I think there was an issue with a vial of lorazepam used

174. on our last patient and it should be reported

175. to the drug manufacturer.

176. What kind of issue?

177. The cap was really hard to take off,

178. almost like it was super-sealed shut.

179. I'm worried it could be a bigger issue.

180. Like?

181. Like maybe the temperature wasn't

182. properly controlled during transportation

183. and the seal on the vial melted shut,

184. which could mean the medication is compromised.

185. Any other vials affected?

186. Uh, just this one.

187. Okay.

188. Check the manufacturer's website,

189. see if there's been a recall of the lot number.

190. And what if this is the first irregular vial?

191. Then hold on to the vial in case

192. there are any other issues.

193. Hey, look who's in the house!

194. Hey.

195. Jake the Snake! It's 11:00 a.m.

196. Aren't you supposed to be in school?

197. Mom let me ditch for Pittfest.

198. How's your mama?

199. Oh, she's restoring some house

200. in Squirrel Hill, so, you know, she's pretty busy.

201. That's cool. You, uh—you looking for Robby?

202. Yeah, he's got our festival passes.

203. Oh, you going together?

204. We were supposed to, but, you know,

205. I decided to go with a friend. - What's her name?

206. - Leah. - Okay. Okay.

207. - Okay, okay. - Don't hold out on us.

208. We need details. Where'd you meet?

209. How long have you been together?

210. We met at junior lifeguards this summer.

211. And we've been dating for two months.

212. Yeah, she's pretty great. - That's sweet.

213. I'm happy for you, kiddo.

214. I'm gonna go find Robby, let him know you're here.

215. Hey.

216. A little advice, man-to-man—

217. always compliment her outfit,

218. hold her hand in front of your friends,

219. and always wrap it before you tap it.

220. Okay.

221. Slowly letting down the cuff pressure

222. until we can identify the exact spot.

223. Oh, I see it. I see it.

224. Right—right there.

225. Okay.

226. Now you can place a figure-of-eight suture.

227. Uh, I've never done one of those before.

228. Look, maybe you should just do it.

229. You should definitely do it.

230. Whitaker's got this.

231. It's easy, just two stitches in one.

232. Take a big bite, a simple interrupted suture

233. anterior to the bleeder.

234. Okay.

235. Okay.

236. Now instead of tying, throw another one posterior.

237. Looks good.

238. Now a normal tie for a figure-of-eight.

239. What did I miss in here?

240. I am so sorry. I-I just—

241. Made an excellent catch and saved Mr. Chazen's life.

242. - Really? - Really?

243. Really?

244. There was a cut arteriole

245. under a ballotable vesicle.

246. If Mr. Chazen had gone home without debridement,

247. the blister could have eroded with uncontrollable hemorrhage.

248. Nice work.

249. Jackson Pollock here might want to go hit the scrubs exchange.

250. Yeah.

251. All right.

252. Next up is an ingrown toenail.

253. It should be pretty quick, though.

254. And—ah.

255. Sherry, you're back.

256. The kids get to school okay?

257. - Yeah. Thanks. - Hey, cool.

258. Well, come with me,

259. and we'll finish up your wound care, okay?

260. Earl, what are you doing out here?

261. I'm hungry.

262. Head back inside, and we'll get you a sandwich.

263. - No egg salad. - Sure. Come on.

264. Excuse me. Excuse me.

265. I've been here for over five hours,

266. okay, way longer than that chick.

267. Can you check the list? Driscoll?

268. Doug Driscoll.

269. E-everybody is seen as quickly as possible

270. and in order of medical care needed.

271. Unless they die waiting.

272. Would you look at that, Mr. Driscoll?

273. It's actually time to bring you back.

274. Thank God.

275. Would you take care of Mr. Driscoll?

276. Yeah, absolutely.

277. Sherry, you're with me.

278. Oh, yeah.

279. Yeah, let's take care of this.

280. Hey, I need a minute.

281. I already put $20 on disgruntled ex-EMT

282. caught outside of our catchment.

283. And I will gladly take your money when that mess is over,

284. but this is about a patient.

285. Kristi Wheeler, 17 years old, pregnant.

286. These are Abbot's fetal measurements from yesterday,

287. and these are mine.

288. 10-5 and 11-2.

289. Well, ultrasound is an art, not a science.

290. Even in the very best hands, the EGA differential can be

291. within three to five days in the first trimester.

292. Definitely room for error.

293. Not if you're here for a medication abortion

294. and you're past the mandated 11-week cutoff.

295. There can also be inter-operator variability.

296. I measured the gestational sac, 11-3,

297. and the biparietal diameter, 11-1.

298. I didn't get a single measurement under 11 weeks.

299. So what are you saying,

300. that Abbot lowballed his measurements to help a teen

301. get the abortion that she wants?

302. Maybe.

303. Well, then you've got two choices.

304. You can go with Abbot's measurements,

305. or you can redo your measurements,

306. go back in, and pick an angle that shows 11 weeks or less.

307. Please tell me you're joking.

308. You were ready to roll up your sleeves

309. and arm-wrestle the Ethics Committee a couple hours ago

310. to override Mr. Spencer's children.

311. What changed? - Apples and oranges.

312. There was a clear, bright line that Mr. Spencer

313. was never going to make it.

314. Falsifying medical records for Kristi is flat-out illegal.

315. She's 17. She deserves a life.

316. Of course she does.

317. But I will not jeopardize my future in the process.

318. You'll be fine.

319. Someone finds out I falsified medical records,

320. I'll get booted from the residency program.

321. You've got tenure.

322. Worst case, you have to take a job in Youngstown.

323. The risks are not the same for you as they are for me.

324. You're right.

325. I'll do it.

326. - What? - Erase your history, physical,

327. and impression from Kristi's chart.

328. It'll be like you never saw the patient.

329. I will take over.

330. I will complete a new chart and upload my own image.

331. Robby, I'm not asking you to—

332. As your attending, it is my decision.

333. I am a certified provider for Mifepristone.

334. You are not.

335. And as a prudent physician, I should examine

336. every patient before I order medication—

337. - Robby. - Yeah.

338. - Jake's here. - Hey. Great.

339. Uh, any word back on Nick Bradley's

340. perfusion study results? - Still waiting.

341. Will you come find me when the imaging's back?

342. These people have already been through enough.

343. Is that Mr. Spencer? - Yeah.

344. - Robby? - Excuse me for one second.

345. I want to go see if I can find Mr. Spencer's children

346. before they leave.

347. You look a little peaked. You okay?

348. I just need a good night's sleep.

349. I'm gonna grab you a grilled cheese

350. before the noon lunch rush; it'll help some color

351. back to your cheeks. - Thank you.

352. I got you.

353. Uh, can someone please help?

354. It's my mother.

355. She fell.

356. What happened?

357. I fell in the yard.

358. I hurt my arm. That's all.

359. Yo, we've been hugging this wall for almost an hour.

360. Relax. We're just gonna take her vitals.

361. Oh, Mom, you've got cuts all over.

362. I fell in the rose bush.

363. I'll be fine.

364. I'm Dr. King. This is Perlah.

365. What's your name? - Ginger Kitajima.

366. Uh, I'm her daughter, Rita.

367. Ginger, did you hit your head?

368. No.

369. Any chance she could have fainted?

370. - I told you. I tripped. - I don't know.

371. I was taking a shower, and she went outside.

372. She's not supposed to go outside anywhere without me.

373. She needs 24-7 assistance with ADLs.

374. Are you the primary caregiver?

375. I'm her only caregiver.

376. Ma'am, what medications are you on?

377. Oh, uh, just one.

378. Risperidone.

379. My mom has schizophrenia.

380. BP 132 over 78.

381. Pulse 84. Sats 98.

382. I haven't seen this young lady around before.

383. Somebody new?

384. Flattery will get you everywhere.

385. Ground-level fall. Good vitals.

386. No head trauma, no AMS,

387. and just an isolated shoulder injury.

388. You have any pain in your belly?

389. No, but next time,

390. buy me dinner before you do that.

391. Okay, let's order some basic labs

392. and get some pain meds on board.

393. And call me when the X-rays are back.

394. Your mom's in very good hands.

395. You're leaving so soon?

396. Oh, I'm never far away.

397. I'll save a dance for you.

398. I'll be counting on it.

399. Looks like more than just vitals to me.

400. That's it. You're on the list, Harley.

401. Aw, shit. No.

402. Perlah, I'm sorry!

403. I take it back! - Too late!

404. You're on the list.

405. Mm.

406. Okay.

407. What?

408. Oh.

409. I like big butts, and I cannot lie.

410. Whoa.

411. You scared me there.

412. Want a pony ride, big boy?

413. - What? - Excuse me, Myrna.

414. I need to discuss a confidential patient issue

415. with my colleague here.

416. We need a little privacy.

417. Catch you later, sweet cheeks.

418. Don't mind Myrna. She's harmless.

419. She's handcuffed.

420. That's why she's harmless.

421. You gotta stay on top of Ozzie's ear infection.

422. His meds are in the fridge.

423. Our dog has really bad allergies.

424. And I changed Ruby's food order to Monday.

425. Bougie bitch.

426. She only likes the good stuff. - Mm-hmm.

427. Like mother, like daughter.

428. Nice to know you still make each other laugh.

429. Make each other laugh.

430. Make each other deliriously happy.

431. Sorry. Didn't mean to get all mushy in front of you.

432. Are you kidding me?

433. You two are the sweetest.

434. I never got to see this kind of love between a married couple.

435. Your parents weren't the lovey-dovey type?

436. My dad died when I was 13.

437. Aw.

438. I'm so sorry.

439. Yeah, me too.

440. He's the reason why I got into medicine

441. and the reason why I'm conducting research

442. on racial disparity in the ER.

443. I'm doing a retrospective chart review

444. on our past five years of patients of color.

445. Is that how you knew what was going on with me?

446. We don't treat sickle cell here

447. as well as they do in other hospitals,

448. but I'm hoping to change that.

449. Status, Dr. Mohan?

450. Still on exchange transfusion and high flow nasal oxygen,

451. but oxygen sats are dropping.

452. She's at 84.

453. - That's really low. - Yes, it is.

454. The goal of exchange transfusion is

455. to reduce the percentage of sickle hemoglobin to under 30%.

456. That is not happening at the rate

457. that your wife needs, which is causing

458. your blood to be unable to carry oxygen,

459. causing further blocked blood cells.

460. - What does that mean? - Dr. Mohan.

461. To prevent stroke or heart attack,

462. we need to get you more oxygen, but we will need to intubate.

463. How long can we wait to see if that's really necessary?

464. Acute chest syndrome can progress very quickly.

465. It is the most common cause of death

466. for patients with sickle cell.

467. It is imperative that we intubate.

468. I-I—

469. I-I-I don't know.

470. Why don't we give you and Ondine

471. some privacy so you can talk?

472. Look, you want to be their friend, but right now,

473. you need to be Joyce's doctor.

474. So get her to sign the consent form

475. and prep for the intubation.

476. 43, 44, 45...

477. Whoa! - 46, 47.

478. Ugh.

479. You're not gonna beat my record.

480. Ohh.

481. How the hell did you stay on for 80?

482. I'm 17, and I'm more fit than you.

483. That kid looks my age.

484. Yeah, he is.

485. What happened to him?

486. Stressed-out 18-year-old took some pills off the internet

487. to help him sleep.

488. They were laced with fentanyl.

489. - Is he gonna make it? - Mm.

490. Poor Huckleberry.

491. Not even 11:30 and you've already been demoted.

492. They had only morgue scrubs left in my size.

493. Then I guess you better not

494. fuck anything else up today, huh?

495. Yo, Donahue. - Yo.

496. You get in on that ambulance-chase action?

497. Yeah, $20 on catch, chop shop, out of our zone.

498. Bold.

499. I like it.

500. What can I do you for?

501. Hypothetical question—

502. would you ever go over a resident's head

503. to the attending?

504. Hypothetically, I wouldn't recommend it

505. unless it's a behavioral issue or harassment.

506. And in that case, you can make a confidential report to HR.

507. What if it's more patient care related?

508. Depends.

509. If it's something minor, leave it alone.

510. If it's something that endangers the patient,

511. then definitely yes.

512. Pick your battles.

513. You don't want to be the intern who cried wolf.

514. - Ahh! - Yeah?

515. Okay, still pretty raw. - Yeah.

516. Let me put some more anesthetic on there,

517. numb you up some more.

518. It's my own fault.

519. I should have known better than to try to make

520. s'mores over a Sterno,

521. but they kept asking.

522. Yeah. The things we do for our kids.

523. Yeah.

524. You have a kid, right? - Yeah.

525. He's 11.

526. And when he, um— when he turned 8,

527. he begged me to go camping for his birthday.

528. We drove four hours to New River Gorge.

529. Took me an hour to set up the tent.

530. Guess how long we lasted.

531. Three hours?

532. 37 minutes.

533. A thunderstorm came out of nowhere,

534. filled the tent with water so fast,

535. I felt like I was being flushed down a toilet.

536. I'm so sorry.

537. Ran out of there like a couple of gutter rats.

538. Ended up celebrating his birthday

539. at 2:00 a.m. with a Happy Meal.

540. Oh, what my kids wouldn't give for a Happy Meal.

541. Yeah, they must, um, have some pretty fancy McDonald's

542. up there in Shadyside.

543. Yeah.

544. That's, uh—that's where you live?

545. It's the address on your patient file.

546. Um, technically, no.

547. I just use the address so my kids can go to a decent school.

548. Right.

549. I know it's illegal, but it's just temporary.

550. - Oh, God. - I promise.

551. No judgment here.

552. My son always comes first, no matter what.

553. Yeah.

554. Even If it means I have to do without.

555. I know, I'm a doctor, right?

556. How bad could it be?

557. But I, uh— I used to be an addict.

558. I even lost custody of my kid.

559. Huh, I never would have guessed.

560. Mm. Yeah.

561. I went through some really dark times

562. before I finally got help.

563. And I've been sober now 9 years,

564. 5 months, and 11 days.

565. And your son?

566. He's good.

567. - Okay. - You know, we're good.

568. He gets to stay with me every other weekend.

569. And, um...

570. We'll be back to joint custody

571. just as soon as I get this stupid thing off next week.

572. Oh.

573. Don't worry. I only killed three people.

574. Oh, God, I'm kidding.

575. - Oh. - I'm kidding.

576. I'm sorry. It was a bad joke.

577. The whole thing was just this...

578. giant misunderstanding.

579. I guess I'm oversharing because I want you to know,

580. not everybody has it all figured out all the time.

581. Yeah.

582. Um, I'm struggling.

583. And I feel like such a bad mom.

584. And every day is so hard.

585. And I don't know what's gonna happen tomorrow

586. or the next day.

587. Sometimes I wonder if they would

588. just be better off without me.

589. Yeah?

590. Do you—

591. Not like that.

592. I just—

593. I've just messed up so much.

594. - Yeah. - And I don't know.

595. You're their mom.

596. You love them, and nothing and no one can replace that.

597. Yeah.

598. You deserve a little grace, you know.

599. Be kind to yourself.

600. Well, you had a normal EKG and chest X-ray.

601. But it looks like you sustained

602. a proximal humerus fracture on the left upper arm.

603. There goes my backhand.

604. That was a joke, dear.

605. Okay, um, because the fracture isn't displaced,

606. the good news is, you don't need surgery.

607. Oh, that's a relief.

608. The bad news is, you do need to wear a sling

609. for at least six weeks.

610. And I have to insist, absolutely no shoulder mobility

611. for the first few weeks.

612. And that means you're gonna have to step up even more,

613. because on top of your usual ADLs,

614. you're also gonna have to help your mom bathe,

615. dress, and use the toilet.

616. I'm so sorry, Mom.

617. This would never have happened if I was more on top of things.

618. Any more on top, you'd be back in my womb.

619. It's going to be fine.

620. I know how hard it can be.

621. I was my sister's primary caregiver

622. until a few weeks ago.

623. Where is she now?

624. Um, she's in an amazing facility in North Hills.

625. I know I can be a burden,

626. but I like being in my own home,

627. just me and my girl.

628. You're not a burden.

629. You're my mom.

630. I'll refer you to Ortho.

631. They'll get you set up with PT and exercises.

632. You're very lucky to have such a caring daughter.

633. Don't I know it.

634. Park a red Subaru in the ambulance bay?

635. Oh. Yes, that's me.

636. Gonna need to move that to open the space for ambulances.

637. Oh. I'm so sorry.

638. - Okay. - Um—

639. I'll walk Rita out.

640. Perlah, would you stay with Ginger for a minute?

641. I'll be right back. - Yeah, no problem.

642. Okay. Um, after you.

643. Look, I-I put your mom's prescription in

644. at the pharmacy, and, uh, by the time

645. you get back from parking,

646. she should be ready to be discharged.

647. Just don't worry.

648. Things will be back to normal in a few weeks.

649. I'm not sure what normal is anymore.

650. I can't even remember the last time I slept through the night.

651. It's just—

652. It's a lot.

653. Um, do you have any support at home?

654. I wish.

655. It's just us.

656. You know, I hired a part-time aide for my sister

657. to cover me when I was at work.

658. It was really helpful.

659. It's out of our price range.

660. I mean, I already work from home.

661. And then there's the cooking and the cleaning

662. and the doctor's appointments.

663. It never ends.

664. You know, caretaker's fatigue is a real thing.

665. You have to take care of yourself.

666. Otherwise, you're gonna end up in here, too.

667. I still don't understand why Kristi needs

668. to go through this a third time with a third doctor.

669. Yeah, that's our bad.

670. Our computerized medical records

671. have been glitching lately, and Dr. Collins' image

672. didn't upload properly.

673. Okay, crown to rump— that's top of the head

674. to the bottom of the butt—

675. is how you measure gestational age.

676. And we are at 10 weeks and 6 days.

677. I made it by one day?

678. I will order the medication.

679. Dr. Collins will go over instructions

680. on taking the pills when they come back from the pharmacy.

681. Thank you so much, Dr. Robby.

682. Oh, I'm glad I could help.

683. Even more glad to see you have such a supportive mom.

684. Okay, take care.

685. Appreciate you stepping up.

686. All good. I got you.

687. Robby, I have Emma Isaacs on line 3 for you.

688. She's the organ donation counselor coming

689. to speak to Nick's parents. - Thank you.

690. What was that all about?

691. - Oh, nothing. - Didn't look like nothing.

692. - Please. - What?

693. You two were once a thing.

694. We dated briefly a million years ago.

695. Never again. - Never say never.

696. Settle down, Jane Austen.

697. The lady doth protest too much.

698. - Mm. - Mm.

699. Jake!

700. There he is— the man, the myth, the legend.

701. And there's the kid who stole my concert pass

702. and gave it to a girl.

703. Where is she? Do I get to meet her?

704. Need an assist!

705. - Hold that thought. - Okay.

706. Travis Johnson, 17, had a tonsillectomy

707. ten days ago at St. Michael's.

708. Started spitting blood about an hour ago.

709. Good vitals. - Hey, Travis. I'm Dr. Robby.

710. How much blood? - Couple mouthfuls.

711. Can you open up for me?

712. Hey, Whitaker, Jesse.

713. Got a post-tonsillectomy hemorrhage.

714. Nebulized TXA, quick as you can.

715. - I'm on it. Let's go. - Let's go, Trauma 2.

716. So this can go south pretty quickly.

717. You up for it? - Well, I can—

718. Of course you are.

719. Ready? Here we go.

720. One, two, three.

721. Take long, slow, deep breaths on that.

722. The TXA is gonna help your blood clot.

723. Uh, any medical problems?

724. No, just a ton of strep.

725. That's why I had the surgery.

726. You take aspirin?

727. Any other medications? - Mm-mm.

728. Lungs are clear bilaterally, no stridor.

729. Okay, sure.

730. You feel like throwing up? Any pain in your belly?

731. No.

732. Labs?

733. Uh, CBC, BMP, maybe coags?

734. Add a type and screen, just in case.

735. Yeah.

736. Good sats at 98%.

737. BP is 115 over 80.

738. Okay, good.

739. Four by four on a ring forceps.

740. Let's take a look. - Okay.

741. Head back, open wide for me.

742. - What do you see? - No active bleeding,

743. but there's some white and dark brown stuff

744. where the tonsils used to be. - Oh, that's good.

745. That's a fibrinous clot. That means the TXA is working.

746. Your parents on the way?

747. They're in Baltimore for a wedding.

748. I didn't want to bother them.

749. Trust me. They're your parents,

750. and you are in an emergency room.

751. It is never a bother.

752. Write their numbers down, and I will call them.

753. Call Head and Neck.

754. Stay with him until they get here, okay?

755. Good.

756. Pen.

757. Can I get the—

758. Sam Wallace, our Good Samaritan who saved

759. a Nepali lady, is in line for a repeat head CT

760. to be sure there's no extension of the intraparenchymal bleed.

761. Okay, so we can dial down the sedation, and,

762. if he's alert, check extubation parameters.

763. - Copy. - Did you get the consent form

764. signed by Joyce the sickler

765. for the intubation? - Not yet.

766. - Jesus fucking— - She's scared.

767. I just wanted to give her some time to talk to her—

768. To do what, make funeral arrangements?

769. Joyce is hypoxic at 84.

770. 84. This goes on much longer,

771. she runs the risk of permanent lung damage,

772. heart attack... - I know.

773. - Stroke, death. - I know.

774. Then move!

775. Now.

776. Just have a seat, and we'll be with you shortly.

777. Oh, I've heard that load of bullshit before.

778. My fucking God.

779. Took me all the way back there just to

780. stick a goddamn thermometer in my mouth, you know.

781. Repeat vitals every four hours.

782. Oh, dang!

783. Saw how it swerved and almost hit the taxi?

784. Mm-hmm.

785. I gotta get out of here; I mean, this thing is

786. totally gonna screw up the traffic to Pittfest.

787. Nice score. You going with Robby?

788. Well, I was supposed to.

789. But I have this new girlfriend,

790. and she's super excited about the lineup, so...

791. So you ditched the old man for a hot piece of ass.

792. Been there, done that.

793. Senior year, Lollapalooza, I met this guy.

794. Think his name was Rich—

795. or was it Rick?

796. Doesn't matter.

797. But he looked like Dave Navarro.

798. Warm breeze, cool grass,

799. a million stars in the sky.

800. Best sex of my life.

801. You had sex in public?

802. We were under a blanket.

803. Oh! It's turning around.

804. It's turning around, baby.

805. Come home to Papa. - Shit.

806. I had money on it crashing in Beaver County.

807. Better safe than sorry.

808. Okay.

809. - Jake, what's up? - Hey, how are you?

810. Where's Rita?

811. Um, she went to park the car.

812. Shouldn't have been more than five minutes.

813. Why don't you dial her number for me?

814. - Did she pick up? - Straight to voicemail.

815. - That's weird. - Yo.

816. Sole caretaker, overwhelmed,

817. exhausted.

818. I told her to take a break, but you don't—

819. you don't think she ditched her mom, do you?

820. I mean, it happens.

821. You're gonna need to use the antibiotic ointment twice a day

822. and come in for a wound check in two days, okay?

823. Mateo, can you grab me enough samples

824. to last a couple weeks? - Yeah, I'm on it.

825. Thank you.

826. Thanks.

827. I really appreciate it.

828. Yeah. No problem.

829. Has Kiara been here yet?

830. No, who's Kiara?

831. Oh, she's the hospital social worker.

832. She can help you out with, like, housing and childcare

833. and food and security— - You told her?

834. - No, I-I— - No, no, it's all free.

835. The system works if you use it.

836. You just have to— - Enough!

837. I don't need your help.

838. Nice speech.

839. Next time, mind your own business.

840. You ever heard of impact over intent?

841. I would never intentionally embarrass anybody.

842. But you did.

843. You didn't have a conversation with Sherry

844. or ask her what she needed.

845. Instead, you walked in here and told her what to do.

846. You gotta slow down, take a beat, and listen

847. instead of judging people.

848. - I don't judge. - Please.

849. You've been eyeing me sideways all day.

850. Look, maybe I have a better perspective because I've been

851. on both sides, but we gotta try to at least

852. put ourselves in their shoes.

853. Listening and building trust will make us better doctors...

854. and better people.

855. Um, I'm sorry.

856. I'm not telling you this to reprimand you.

857. I'm trying to teach you to help you.

858. Wait, uh, what about Sherry?

859. I doubt she'll be back.

860. But sadly, there will be many, many more just like her.

861. No. No, no, no.

862. He—he had the surgery at St. Michael's,

863. but he's here now.

864. No, he doesn't have a car.

865. His parents are out of town.

866. Okay, okay, well,

867. how am I to send him back to St. Michael's,

868. call him an Uber?

869. You can't—that doesn't make—

870. hey, hello.

871. Hello!

872. What's wrong?

873. Um...

874. They said it is not their job to fix

875. another hospital's problem.

876. Don't worry about it, though. I'll talk to my attending—

877. Oh, shit!

878. Uh, I need a little help here!

879. Okay, come on, open up.

880. It's a post-tonsillectomy hemorrhage.

881. Uh, Yankauer and sponge stick.

882. He was stable. Then it just opened.

883. Call the blood bank.

884. Two units, whole blood. Get a second line.

885. Head and Neck wouldn't come down to see him.

886. - Assholes. - Tachy to 120.

887. His sats are down to 90%.

888. Okay, get a high-flow nasal cannula,

889. 100 of ketamine.

890. Set up the GlideScope.

891. Hold suction.

892. I'm gonna try for direct pressure.

893. If Head and Neck still won't come down, call Garcia.

894. You're good. You're good.

895. Okay, before we begin, let's take a time-out.

896. This is Joyce St. Claire.

897. Procedure is endotracheal intubation

898. for hypoxia due to acute chest syndrome.

899. We'll be using video laryngoscopy

900. and an 8-0 ET tube with a 7.5 on standby.

901. Induction with 75 of propofol, 100 rocuronium.

902. Got it.

903. For backup, we have a bougie and an LMA ready.

904. Yep.

905. Any questions or concerns before we start?

906. I wanna be awake.

907. We can't perform an intubation that way.

908. I mean after.

909. After, we will lighten your sedation.

910. You won't be able to talk, but you can use a pen and paper

911. or an iPad to communicate.

912. I love you.

913. Till the end of time.

914. Robby, Trauma 2 right now.

915. - Cover the intubation? - Of course.

916. - What happened? - Bleeder opened up.

917. Ketamine on board to intubate.

918. Sats holding at 97.

919. - Can you get an airway? - Come on.

920. Let's lie him down.

921. Keep pressure on the scab.

922. Nothing but blood.

923. Can't see the cords.

924. Sats 94.

925. Not sure we have room for the tube with the sponge stick.

926. If I pull out, there's gonna be even more blood.

927. Doesn't look like you secured that airway.

928. - He's working on it. - Bougie.

929. Open a crike tray and prep the neck.

930. Hold on, I'm going in blind with the bougie.

931. I might be able to feel the tracheal rings.

932. And I might have a three-way with Madonna.

933. Move.

934. Not happening.

935. Pressure.

936. Make room for the grown-ups.

937. Okay, okay. Hold on, hold on.

938. We can try a retrograde intubation.

939. - A what? - There's no obstruction.

940. We just can't see what we're doing.

941. So we take a needle,

942. and we put it in the cricothyroid.

943. We run a guide wire up and out the mouth,

944. and we slide the ET tube up over the wire.

945. - Never seen one before. - Sats 90.

946. No time to play MacGyver with this kid.

947. Time to crike. - It'll be quick.

948. You got one shot, and then I cut.

949. Propofol and rock are on board.

950. Now we wait for the sedative and paralytic to start working.

951. Should Dr. Robby be in here?

952. Between Dr. Mohan and myself, we've done hundreds of these.

953. I'm getting sleepy.

954. I'm right here, babe.

955. Okay, I'm in.

956. Guide wire.

957. Let me know when you start to feel it up top.

958. Nothing yet.

959. More suction. - I'm trying.

960. Mm. Still can't find it.

961. Well, keep feeling in there.

962. It's gotta be there somewhere.

963. - Maybe it's curling up. - Sats down to 89.

964. - Guys, this is not working. - Just give me a second.

965. - Until he arrests? - Oh, my God.

966. I'm gonna lose another patient.

967. Shut up, Whitaker. Let's get on this.

968. Sats down to 87.

969. Okay, I'm gonna redirect the wire.

970. Sats still dropping. 86.

971. - You got this. - Mm-hmm.

972. Ondine, if you'd like, you can watch on the screen.

973. I'm okay.

974. Excellent view of the cords, Dr. Mohan.

975. I'm in.

976. Inflate the balloon.

977. Good breath sounds bilaterally.

978. Sats 92 and rising.

979. That's it? You're done?

980. Yes.

981. It all went perfectly.

982. How long until she gets better?

983. Depends.

984. It can take anywhere from a few days

985. to a few weeks for the lungs to heal

986. from acute chest syndrome.

987. I can ask the ICU to set up a recliner for you

988. in Joyce's room so you can stay with her.

989. Thank you both so much.

990. You're welcome.

991. Take care.

992. Sats 84. We need to bag him.

993. - Still not seeing it. - I'm suctioning like crazy.

994. Okay, we're done playing doctor.

995. Lose the wire. I'm criking this kid.

996. All right, we tried. I'm sorry.

997. No, wait. Wait.

998. I've got it.

999. You still don't have an airway.

1000. Okay, keep the laryngoscope in place

1001. so the tube passes easily.

1002. Pass the T, the T tube over the wire.

1003. - Come on. - Hang on to that wire.

1004. Do not let go of that wire.

1005. Okay.

1006. Okay, I'm gonna give you a little slack

1007. so you can get past the cords.

1008. Yeah, yeah. I feel you at the trachea.

1009. 25 centimeters at the lips.

1010. That ought to do it.

1011. Pull the wire, bag him.

1012. Balloon's up.

1013. Yellow on CO2. That's good.

1014. That is very good.

1015. Good breath sounds bilaterally.

1016. Sats coming up.

1017. 90, 92.

1018. Guess you're gonna have to save that scalpel

1019. for another day. - You guys got lucky.

1020. No, we got skills, baby.

1021. We got skills!

1022. Keep gauze on the clot.

1023. Yeah, copy.

1024. Ordering propofol and fentanyl drips.

1025. Oh, nice of you to join us, Dr. Flores.

1026. Sorry, I got stuck in a nasty radical neck dissection.

1027. Still bleeding? - Not with direct pressure.

1028. We got the airway. You get the bleeder.

1029. OR's standing by.

1030. So I can cancel the Uber?

1031. Let's get him upstairs.

1032. Fresh sponge stick for you, Whitaker.

1033. You need me to stay with the—

1034. Your patient. You did a good job.

1035. It's only till the anesthesiologist takes over.

1036. You got it? - Yeah, I got it.

1037. Get yourself a fresh pair of scrubs

1038. on your way back down.

1039. Um, I'm sorry that took so long.

1040. I was just— - Don't apologize.

1041. What you did in there, building a relationship

1042. with your patients, earning their trust,

1043. that's what this is all about.

1044. Robby doesn't seem to think so.

1045. Don't worry about him.

1046. You know, I should be apologizing to you.

1047. Slo-Mo, you deserve better.

1048. Keep doing you, Dr. Mohan.

1049. Where'd you get that move?

1050. Retrograde intubation, that's an Adamson special.

1051. I learned that from the best.

1052. Well, you're not too shabby yourself, Professor.

1053. Yeah, that got kind of rough in there.

1054. You kept your composure, though—

1055. exactly the kind of candidate they want

1056. for the ED Medical Education Fellowship.

1057. Oh, there's probably over 50 applicants for that one slot.

1058. Yeah, probably.

1059. But I know that they like to go with someone that they

1060. know from firsthand experience has

1061. the skills to be successful.

1062. At least that's what I told them in my letter

1063. of recommendation.

1064. Thank you.

1065. Mm-hmm.

1066. Glad you stuck around.

1067. It's not like I had a choice, did I?

1068. No, not really.

1069. So how's your day going?

1070. Uh, it's going.

1071. Cool, cool, cool.

1072. Why do you ask?

1073. Guy can't ask?

1074. You never ask me about my work.

1075. What gives?

1076. Mom wanted me to ask because she just wants

1077. to make sure that you're doing okay.

1078. That's very sweet of her. I'm doing fine.

1079. Thank you for these again.

1080. You can thank me by finally introducing me

1081. to your girlfriend.

1082. - Not today but soon. - Have fun.

1083. Hey, I know it goes without saying, but please be safe.

1084. - I will. - Seriously.

1085. Don't take anything from anyone.

1086. I've already seen two fentanyl overdoses today.

1087. It's not even noon. - I promise.

1088. - Okay. - Basketball Sunday?

1089. Yep, wouldn't miss it.

1090. Hey, before you go, before you go.

1091. Please don't hand me a condom.

1092. Condom?

1093. I was gonna give you extra cash.

1094. Wait, are you having sex?

1095. Thank you.

1096. Looks like the driver lost control as the police cars

1097. were closing in. - Oh.

1098. Uh, the ambulance has definitely stopped.

1099. Check it out.

1100. It's difficult to tell from this angle,

1101. but it does look like they may have hit something.

1102. - Damn! - That's in our zone.

1103. Ambulance crashed in our catchment.

1104. Get ready for incoming.

1105. How many you think?

1106. Other than the driver? No idea.

1107. Since you're past ten weeks,

1108. you'll need to take mifepristone twice,

1109. once now and once in 24 hours.

1110. Then 24 hours after that, you'll take misoprostol,

1111. two pills which dissolve between the cheek and the gum,

1112. then two more of the same pills six hours later.

1113. That's a lot to remember.

1114. Everything is clearly labeled with the names of the meds,

1115. the dose, and the exact time to take them.

1116. Will it hurt?

1117. You can expect some vaginal bleeding.

1118. There may be some cramping,

1119. like when you're on your period.

1120. If you're bleeding more than two pads an hour

1121. or the pain gets to be too much,

1122. come back in and see us.

1123. And I'll be with you the whole time.

1124. Kristi?

1125. Kristi!

1126. What the hell are you doing here?

1127. Hey, language!

1128. And I should be asking you the same thing.

1129. Excuse me. Who are you?

1130. - I'm her mom. - Mom?

1131. Aren't you her mom?

1132. I can explain.

1133. No, that's my sister, Lynette.

1134. I am Kristi's mother.

1135. Kris—Kris, baby, what are you doing here?

1136. I'm here for an abortion.

1137. Did you do it already?

1138. - Not yet. - Okay. Thank God.

1139. Okay, okay, can we all just take a step back here and—

1140. Mom, I want this. This is my decision.

1141. - No. - Just listen to her, El.

1142. You can shut up!

1143. You have done enough.

1144. My daughter is a minor,

1145. so she can't get this abortion

1146. without my say-so, right?

1147. Is that right?

1148. That's correct.

1149. Then there is no way this is happening.

1150. Not now, not ever.