The Pitt 2x13

1. - You know this guy? - Orlando Diaz.

2. We were treating him for DKA when he eloped.

3. - How far did he fall? - 20 feet or so.

4. - Anyone see him pass out? - No.

5. They went looking for him after he didn't answer his radio.

6. Pupils equal but sluggish.

7. He left against medical advice.

8. On my count, three, two, one.

9. Dr. Ellis on the case. Day shift, we got this.

10. - I'm staying. - Continuity of care.

11. Dr. Al-Hashimi, why don't you go cover

12. sign-out rounds with Dr. Abbot?

13. Shen, you too. - Got it.

14. OK, let me know if you need anything.

15. - Lungs are up bilaterally. - Pelvis is stable.

16. Right tib-fib hematoma, deformed right forearm.

17. Ruptured TM on the left with sero-sanguinous fluid.

18. That means basilar skull fracture.

19. We've got a diabetic patient, 20-foot fall.

20. BP 204 over 98, pulse 56.

21. Dr. Mohan, what do those numbers indicate?

22. I'm trying to treat the patient.

23. It's the Cushing's reflex.

24. From increased intracranial pressure.

25. Yeah, we need to get him to CT right away.

26. No free fluid in the belly.

27. - Any family to notify? - Wife and three kids.

28. Is there a card to sign for Robby?

29. No, he said no card, no presents.

30. Oh. Was there a cake?

31. Oh, he didn't want that either.

32. That sucks. I need some cake.

33. Patient was injured when they raided a restaurant.

34. And they actually arrested the nurse?

35. - With a takedown and zip ties. - Damn.

36. Crus, you, uh, know the computer downtime drill?

37. Yeah, no biggie.

38. I prefer to treat 'em without labs and X-rays.

39. Welcome back.

40. If you do have orders for labs and X-rays,

41. clipboards go here.

42. If it's just nursing orders, here.

43. Please write neatly, for God's sake.

44. Oh, Monica, this is Nazely, new intern.

45. - I don't need to know that. - So nice to meet you.

46. Looks like you and me, Jack.

47. Yeah, who's our senior?

48. - Dr. Henderson. - Excellent.

49. Night shift's on Crus control.

50. You hear ICE brought us a patient?

51. Oh, yeah? How'd that go?

52. There was some collateral damage.

53. They arrested Jesse.

54. - For what? - Assaulting a federal officer.

55. Are you fucking kidding me?

56. Oh, Dr. Al-Hashimi,

57. this is Nazely Toomarian— new intern.

58. OK, everybody, let's huddle up.

59. Before we start,

60. let me address the elephant in the room.

61. For those of you who don't know,

62. Jesse tried to intervene

63. when a federal agent was handling his patient,

64. and both he and the patient were taken away by ICE.

65. - Did he punch the guy? - No.

66. He put out a hand to stop him, made physical contact.

67. It was a little bit more than that.

68. The hospital lawyers are on the case,

69. and we will brief the staff every 12 hours

70. at sign-out rounds with an official update.

71. In the meantime, don't feed the rumor mill.

72. You may have also heard that new grad nurse Emma here

73. was assaulted by a patient. - I—I'm fine.

74. Please don't forget "code hula hoop,"

75. and with risky patients,

76. always keep a path to the door clear.

77. Sounds like one hell of a day.

78. And we're still dealing with downtime,

79. so day shift should brief night residents

80. about the protocol—

81. Hey!

82. Oh, all right!

83. Oh, thank God.

84. Yeah, not so fast.

85. Every chart from the last five hours

86. needs to be scanned into the Electronic Health Record

87. and checked for accuracy...

88. - Um, whose job is that? - Day shift.

89. With a completed and signed T-sheet.

90. - Are you kidding me? - That's gonna take forever.

91. We will set up stations for scanning.

92. OK, everybody, let's get moving.

93. Triage is 20 behind. Gotta help 'em clean up.

94. I'm skipping rounds.

95. Consider yourself lucky.

96. Should we join them?

97. Might as well witness the magic.

98. It's like changing of the guard at Buckingham Palace.

99. Except we're allowed to smile.

100. "Smile though your heart is aching."

101. Plain films, right tib-fib

102. and right forearm after CT.

103. Got the chem-8. Blood sugar's 284.

104. That's not too bad. Potassium looks good.

105. Mm-hmm. Anion gap's up at 14.

106. It was 24 this morning.

107. He's definitely improving.

108. The DKA is resolving.

109. So what made him pass out?

110. It's hot as hell out there.

111. He could have been dehydrated from sweating.

112. Or he could have had an N-STEMI or a posterior CVA.

113. Ready to roll.

114. - I can babysit him at CT. - Thank you.

115. I'll stay in case he needs the OR.

116. Hey, we're back up.

117. It's about time.

118. - Ooh, Robby. - Yeah.

119. I got intel on where ICE has taken Jesse.

120. Intel from who?

121. Uh, my brother-in-law's a cop.

122. So he'll be processed at DHS Southside

123. and then transferred to ICE detention in Clearfield.

124. Clearfield? That's two hours away.

125. Mm-hmm.

126. OK, I'll let the hospital attorneys know.

127. - How are you doing, Oliver? - Alive and kicking.

128. Uh, Mr. Haas.

129. Pulmonary edema after missed dialysis,

130. now stable with his son Mason at the bedside.

131. - Hello. - I'm Dr. Shen.

132. I'll be back.

133. Dialysis tech says

134. I'm off the machine at 10:42.

135. Hit the call light, and I'll come running.

136. South 21 next...

137. Mr. Digby.

138. J-just Digby.

139. Dr. Mohan's patient.

140. Forearm cellulitis, admit med-surge.

141. Awaiting a bed. - I can take him.

142. Sold to Dr. Toomarian.

143. Moving right along.

144. Get enough to eat?

145. We'll be back.

146. Lillian Stegman. Tweaked her knee water-skiing.

147. Doing a 360 off a 5-foot ramp.

148. Ooh, respect.

149. X-rays ordered in triage.

150. That was hours ago.

151. Ma'am, I'm Dr. Crus Henderson.

152. Let's get you home real fast.

153. - That would be wonderful. - OK, heading to North.

154. Thank you.

155. Looks like our first scanning station is almost ready.

156. Whitaker, Santos, after rounds, this will be your post.

157. - Seriously? - For... how long?

158. Till we mop up this mess.

159. And away we go.

160. All right, now you know everything

161. there is to know about rounds.

162. Fascinating, right?

163. Uh... yeah.

164. Here, I got something better for you.

165. So, Digby, we're gonna find you some new clothes,

166. but my friend Emma and I wondered if you'd like

167. to get cleaned up a bit first.

168. I already had a shower.

169. I know, and you look good.

170. But the offer also comes with a shave and a haircut,

171. if you're interested.

172. No pressure—like I said,

173. you already look great.

174. - Sure, I guess. - Fantastic.

175. All right, kid, fill that basin with some warm water

176. and lather him up.

177. - Hey, stay safe out there. - Back at you in here.

178. Hey, Cary.

179. You were on scene with Orlando, right?

180. Did you notice anything about his fall?

181. Like what?

182. Like, um, if there was a break in the railing

183. or if there were security cameras?

184. Too busy working on the guy—

185. IV, intubation, backboard, splint.

186. Thanks.

187. Oh, two names is a start.

188. Pretty soon, we'll retire the clipboards.

189. Baby Jane Doe in Pedes?

190. Uh, yeah, abandoned

191. in the waiting room bathroom at 7:30 a.m.

192. - Safe haven drop-off? - No, she's too old for that.

193. At least two months. - I'll take her.

194. Awaiting foster placement by CYF.

195. - What if the mom comes back? - Call the cops.

196. Day shift, get to work scanning.

197. Night shift, the room numbers

198. on top of the dry-erase board need a doctor.

199. - Who's in BH-1? - Psych hold, danger to self.

200. What's the story?

201. Doctors King and Langdon were on the case.

202. It's a sad story— she says her 5-year-old

203. snuck into the back seat of the car to take a nap.

204. Heat stroke.

205. Mom was extremely distraught. Walked out into traffic.

206. Grady Barnhill, wheezing

207. and not responding to albuterol.

208. Pulse ox 87. His mother, Naomi.

209. - OK, Trauma Two's open. - On our way.

210. Uh, Mom, history of asthma? - His whole life.

211. Never this bad. - Barely moving air.

212. Using all his accessory muscles.

213. Call RT!

214. Uh, continuous nebs, 20 milligrams an hour.

215. We have a home nebulizer.

216. I've been giving him albuterol every hour.

217. Ready?

218. On my count, one, two, three.

219. Does he take any other medications?

220. Just the albuterol.

221. He used to be on montelukast and Symbicort.

222. Why did you stop that?

223. Because he lost his Medicaid two months ago.

224. He's so tight, nothing's getting through.

225. - Mel, EpiPen. - On it.

226. 0.3 milligrams.

227. That may open his lungs so the nebs can work.

228. All right, Grady, shot in the thigh.

229. Hey.

230. Something to scan?

231. Critical labs on North Three.

232. Oh, it's, uh— it's not my patient.

233. She's about to be.

234. I'm, uh— I'm off the clock, so...

235. These were ordered three hours ago from triage,

236. so, technically, she is a day-shift patient.

237. Just get the intern started.

238. I got a meeting upstairs with admin

239. to get things back on track.

240. Sorry. Everyone else is tied up.

241. That's OK.

242. How'd you get stuck on night shift

243. for your first rotation?

244. Just lucky, I guess.

245. Yeah, if you like a good horror movie.

246. - Where was med school? - Uh, UC Irvine.

247. - California, right? - Yep.

248. Pittsburgh's a little different.

249. Yeah, a lot more humidity.

250. Yeah, that'll go away

251. with your first foot of snow.

252. Uh, hi, Mrs. Davis.

253. I am Dr. McKay. This is Doctor...

254. - Toomarian. - Hello.

255. Uh, your labs show a lot of inflammation in your liver.

256. - Is that why I'm so nauseated? - Definitely, yeah.

257. Have you, um, noticed a change in your skin coloration?

258. I've been using this bronzing cream

259. so I don't look like a ghost in my bathing suit.

260. Do you remember the name of the bronzer?

261. It could have a chemical that can cause—

262. Oh, no, no, it's 100% natural.

263. It's DHA from sugar beets. - OK.

264. Why would my liver be inflamed?

265. Uh, there's a lot of possibilities.

266. Are you taking any prescription medications?

267. Not a single one.

268. - Tylenol? - God, no.

269. We have to ask everybody about injection drug use.

270. Never.

271. Raw clams or oysters?

272. I'm a vegan.

273. One step at a time, OK?

274. We'll be back.

275. Digby, Haas, now on the big board.

276. Progress.

277. So he's just been waiting

278. in the hall the whole time?

279. OK, well, can you maybe get to him next?

280. Thank you.

281. Duke goes to CT, and they bump him.

282. Yeah, he may end up waiting for hours over there.

283. Oh, look at that. 7:15 already.

284. Just a few more loose ends to tie up.

285. You got more loose ends than a macramé wall hanging.

286. My mom had one. Took up the whole goddamn wall.

287. Seriously, you should think about signing out

288. and hitting the road. - Yeah, maybe you should too.

289. Oh, that's right, you sent Lena home.

290. Are you planning on calling in a replacement,

291. or are you just gonna work till sunrise?

292. If I have to.

293. Oh, so you get to go the extra mile,

294. and the rest of us just get accused of being martyrs.

295. - Robby. - Excuse me.

296. What's the word? - No subdural, no epidural.

297. Diffuse brain swelling with effacement

298. and compression of the ventricles.

299. C-spine? Chest-abdomen-pelvis?

300. Uh, left pulmonary contusion, no intra-abdominal hemorrhage.

301. Which means I'm off the hook.

302. I'll send Neurosurgery down.

303. If he doesn't need the OR, why Neurosurgery?

304. - Wait and see. - Let's get busy.

305. CVP and an art line.

306. Orlando. Orlando, squeeze my hand.

307. Open your eyes.

308. We already know his GCS is going to be three.

309. Hey, Javadi, anti-seizure prophylaxis?

310. - Keppra, 20 migs per kilo. - Mixing it now.

311. Gotta get this brain swelling down, Samira.

312. How we gonna do that?

313. Samira? - What?

314. We have to lower the intracranial pressure.

315. - Mannitol. - Not the best.

316. Can cause diuresis and hypotension.

317. Then hypertonic saline.

318. 23%. 50 cc's through a central line.

319. Still tight as a drum.

320. Five minutes since the epi.

321. He can have one more EpiPen.

322. Sats are borderline, 87.

323. How about BiPap? 10 over 5.

324. Yes, with in-line nebs.

325. All right, Grady, shot number two.

326. Might as well throw in some magnesium, 50 per kilo.

327. I'm sorry. He's not ventilating.

328. We should be ready to intubate.

329. With an asthma patient?

330. There's a high risk of cardiac arrest.

331. Naomi, has he ever been put on a breathing machine before?

332. - Never. - Hospitalized?

333. No, we could always break him with the Symbicort.

334. We're gonna give the current treatment

335. a few more minutes to help him turn the corner.

336. I could probably do this myself

337. now that my cast is off.

338. Oh, that's OK.

339. I don't mind.

340. How long have you been a nurse?

341. This is my first day.

342. You're doing really good.

343. Thank you.

344. - Oh, shit, you OK? - Yeah.

345. There's water on the floor.

346. Sorry! I—I might have spilled.

347. Yeah, no worries.

348. We're gonna have to sort these all by patient

349. before we scan them.

350. Is, uh, Joy still around?

351. I heard she left at 6:59.

352. - Smart girl. - Mm-hmm.

353. You know what? Find Ogilvie. He's such an ass-kisser.

354. He might stay and scan all the charts himself.

355. Oh, he, uh, scrubbed in in the OR,

356. scrubbed in on the ruptured triple-A.

357. Oh, the kidney stone that wasn't.

358. That'll be four hours at least.

359. So are you still going to Amy's after work?

360. Yeah, maybe just for tonight,

361. after Robby briefs me on all the house stuff.

362. Sounds fun.

363. When he asked, it was hard to say no.

364. Sure.

365. It's gonna be very weird without him here.

366. Yeah.

367. You think Dr. Al-Hashimi can handle it?

368. In a word, no.

369. She's smart.

370. It takes more than that.

371. Yeah, well, at least

372. it's only three months.

373. Yeah, three long months.

374. Then you need to find a new home.

375. Not necessarily.

376. I mean, if I wanted, I could just check on

377. Robby's house once or twice a day, you know.

378. Why would you do that?

379. I don't know. Why not?

380. Hypertonic's in.

381. Maintenance LR in the AC.

382. Looks like a halo sign.

383. Cerebrospinal fluid from a basilar skull fracture.

384. The halo sign is neither sensitive nor specific for CSF.

385. Saline, tap water, and runny noses

386. all separate from blood.

387. - Hello, Linda. - Robby.

388. Division chief working on a holiday weekend.

389. Well, somebody's got to.

390. Saw the scans. This guy needs an EVD.

391. External ventricular drain to take down the pressure.

392. Because CPP equals "MAP" minus ICP.

393. Cerebral perfusion pressure in the brain

394. equals mean arterial blood pressure

395. minus the pressure in the skull.

396. ICP less than 22

397. predicts survival and favorable outcome.

398. CPP from 60 to 70 reduces morbidity and mortality.

399. Can somebody assist?

400. Dr. Mohan?

401. I'm good.

402. Samira, you should lend a hand.

403. I said I'm good.

404. - Javadi? - I don't think so.

405. Javadi?

406. As in, daughter of Raymond and Eileen?

407. I was at your mother's baby shower.

408. She was a resident.

409. You were in utero.

410. I don't know how she got through

411. motherhood and training.

412. Feel free to join me.

413. Oh, my—my shift was over a while ago.

414. OK.

415. Masks all around. Two sterile gowns.

416. We brought the surgical towels. Just need some Betadine.

417. This is kind of an amazing opportunity.

418. I'm exhausted.

419. The Chief of Neurosurgery is here.

420. She's kind of a legend.

421. Maybe one of the night residents can do it.

422. Is this about the volvulus case from earlier?

423. 'Cause if it is, you made a mistake.

424. You need to move on.

425. I do not want to come back here and find that

426. you've applied for a residency in derm.

427. Step up to the plate. Do it.

428. Javadi will assist.

429. Excellent.

430. You know, I think Eileen did her first EVD with me

431. back when I was a brand-new assistant professor.

432. Time flies.

433. How you doing, Grady?

434. Still retracting.

435. - Any improvement? - Not really.

436. You feeling tired?

437. - Do we have Aerogen in the ED? - Just in the unit.

438. How fast can you get back?

439. Two minutes if I take the stairs.

440. Go.

441. Uh, Aerogen?

442. It has a 5-millimeter mesh

443. that vibrates over 120,000 times per second.

444. Dr. Al-Hashimi?

445. You OK?

446. Uh, you were telling us about Aerogen.

447. Dr. Shen can explain.

448. It produces droplets in the 2- to 5-micron range

449. for medication delivery.

450. - How's it going? - Just about to start.

451. Securing the art line here.

452. Measure twice, cut once.

453. We enter 11 centimeters back from the nasion,

454. 3 centimeters lateral.

455. Without any direct imaging?

456. No, straight shot into the lateral ventricle—

457. tried and true since 1890.

458. OK, go ahead with the incision.

459. Hey, you worked with Dr. Al-Hashimi at the VA.

460. I did.

461. For how long?

462. During my R2 rotation

463. and then one again last year.

464. OK. Hand drill's all set.

465. Maybe you should do this part.

466. No, no, there's a safety stop here.

467. You can't go too deep.

468. It's not brain surgery.

469. OK.

470. Stay perpendicular. - OK.

471. Good.

472. All right, now, four turns

473. to get through the outer table...

474. - Yep. - Then half turns

475. till you penetrate the skull.

476. Three, four.

477. One...

478. Holy smoke!

479. I thought it was Tom Cruise for a second over here.

480. Nice job. How's that feel, Digby?

481. - Pretty good. - I bet.

482. What do you say we trim up

483. those gorgeous locks of yours now?

484. I don't like having my hair cut.

485. I get it, Rapunzel, but you need your ears lowered.

486. You'll feel better with a fresh summer look

487. that won't go unnoticed by the ladies.

488. - Maybe just a trim? - Great.

489. I'm thinking a pixie cut.

490. - What? - I'm kidding.

491. I cut my husband Benji's hair all the time.

492. Trust me, you're gonna look fabulous.

493. When's the last time you had a haircut?

494. Maybe my daughter's wedding a few years ago.

495. Where?

496. St. Sebastian,

497. Our Lady of Mount Carmel Parish.

498. Does your daughter know where you are?

499. Of course. We all live in Pittsburgh.

500. In fact, they live in my old house.

501. Your daughter lives in your house?

502. Yep.

503. Where do you live?

504. Wherever I want.

505. You're gonna pass it 5 to 6 centimeters

506. from the inner table of the skull, OK?

507. Centered...

508. perpendicular...

509. aiming for the medial canthus.

510. All yours.

511. A-and just keep going?

512. You'll feel a pop when you pass

513. the ependymal lining.

514. Art line is calibrated. Good to go.

515. Titrate the nicardipine to a MAP of 85, please.

516. And if we can get the intracranial pressure

517. down to 20?

518. Dr. Mohan?

519. I'm sorry.

520. MAP of 85, ICP of 20?

521. Um, cerebral perfusion pressure 65.

522. Which gives him the best shot at survival.

523. A third of patients like this die.

524. Half have long-term disability.

525. We'll know in two weeks if there's a possibility

526. for a good prognosis.

527. Felt a pop.

528. Remove the stylet.

529. OK, let it drain a bit.

530. And now pinch it shut.

531. Perfect.

532. BP is down, 190 over 88.

533. Heart rate's 67.

534. How are you guys doing?

535. Yeah, making some progress.

536. You seen Abbot?

537. Not since rounds.

538. He asked me to see a patient with the night intern.

539. And you said yes?

540. 48-year-old woman, new onset jaundice,

541. elevated liver enzymes, no history of alcohol use.

542. Take your pick—

543. hepatitis A, B, C, D, or E.

544. - No risk factors, no fever. - Tylenol?

545. Never, and no prescription meds.

546. Does she eat polar bear liver?

547. It can cause vitamin A toxicity.

548. - No. - Yeah.

549. She, uh, doesn't eat meat,

550. kind of a health nut.

551. Well, maybe she's gulping down

552. cod liver oil to prevent measles.

553. No. Vegan, no fish.

554. Would you, uh, mind laying eyes on her?

555. Seriously?

556. You have a way of figuring out the weird stuff.

557. Take the compliment.

558. OK, fine.

559. Five minutes at the bedside— that's it.

560. I'm already gonna be here for hours as it is.

561. Thank you.

562. What am I doing—

563. - Definitely improving. - Tidal volume's up.

564. Wheezes now expiratory only.

565. Oh, making some progress.

566. You feeling better, baby?

567. You scared the shit out of me. - Language!

568. Does he have a primary-care doctor?

569. Not anymore.

570. How do you get his prescriptions renewed?

571. Neighborhood clinic. We pay cash.

572. Albuterol's cheap. - Symbicort?

573. Without Medicaid, 400 bucks a month.

574. Just for a little inhaler?

575. Trocar is on the tube.

576. I tunnel underneath the scalp about 5 centimeters

577. and poke through.

578. - To prevent infection? - Mm-hmm, exactly.

579. Now you hold the knuckle steady while I pull it through.

580. And you can staple the wound shut.

581. That looks like something from Home Depot.

582. Yeah, big Fourth of July sale.

583. The brain pressure is measured by

584. the height of the fluid column.

585. We need to calibrate it to zero at the level of the tragus.

586. Stopcock's on, ready to attach.

587. First troponin's normal,

588. but you need a second to rule out MI.

589. Hey, can you step out for a second?

590. I really did do everything I could

591. to try to make Orlando stay.

592. Yeah, I don't doubt it.

593. I wanted to ask you about

594. Dr. Al-Hashimi at the VA.

595. Did you ever notice anything unusual about her behavior?

596. Um, like what?

597. Lapses in focus, attention?

598. No, she was always on top of her game.

599. But this morning when she was checking labs on Baby Jane Doe,

600. it was like she zoned out for a few seconds.

601. Maybe she was just tired.

602. No congestion, nodules,

603. or cirrhosis.

604. Good-looking liver.

605. I should not be sick.

606. I work so hard to stay healthy—

607. diet, exercise, eight hours of sleep.

608. I can't remember the last time I got eight hours.

609. Maybe you should try sleepmaxxing.

610. Oh, you definitely should.

611. Yeah, cold room, white noise, eye shades.

612. Kiwis before bedtime, lettuce water, mouth taping.

613. Who do you follow for health?

614. A few naturopaths and some functional healers.

615. Do you—do you buy vitamins from them?

616. Oh, no, no, I don't take vitamins.

617. Food is the best medicine— kale, blueberries,

618. kidney beans, turmeric. - Turmeric?

619. Uh, how long have you been taking that?

620. For a few months. It's an anti-inflammatory.

621. It detoxes the body, and it can prevent Alzheimer's.

622. How much do you take?

623. 500 milligram capsules,

624. but I take five a day.

625. What?

626. With doses that large of turmeric,

627. there have been cases of liver failure.

628. From eating a spice?

629. All right, Digby, I think you're good to go.

630. Mm-hmm. Would you like to see?

631. I haven't looked like this in a long time.

632. Your family won't recognize you.

633. Then how will they find me?

634. They—they won't know what I look like.

635. They won't know this is me.

636. Of course they will.

637. They know your voice.

638. They know where you hang out.

639. They even remember that you used to look like this.

640. They remember the wedding.

641. Did you dance with your daughter

642. at her wedding?

643. I did.

644. Then she will always remember you.

645. - Yeah. - OK.

646. Hey, I was just looking for you.

647. - What's up? - You tell me.

648. The, uh, asthma patient. - What about him?

649. Seemed like you were hesitating

650. talking about using Aerogen.

651. I was wondering if you were having second thoughts.

652. No. Just thinking.

653. About?

654. The best treatment plan for the patient.

655. And I think he's on it.

656. Anything else? - I don't know.

657. You tell me. Anything else I need to know?

658. I don't think so.

659. This is Dr. Robby in the ED.

660. I'm checking on a patient, Ekins.

661. We can take Larson and Stevens off the dry-erase.

662. Consider it done.

663. He's in the scanner now?

664. Oh, great.

665. No, I was just calling to confirm.

666. Thank you.

667. Any new information from upstairs?

668. Nothing we don't already know.

669. Same old story, huh?

670. You think we should take up a collection

671. for Jesse for—for bail money?

672. They don't usually set bail

673. until after you've appeared in front of a judge.

674. With the holiday, it's not likely to happen till Monday.

675. So he's gonna be locked up all weekend?

676. That sucks.

677. It does suck.

678. Dr. Langdon, Grady's worse— much worse.

679. - Need an attending? - Uh, no, we have Shen.

680. Sat's down to 83.

681. - What's happening? - Give us a minute.

682. He's tiring out.

683. Ketamine and rock. It's time to intubate.

684. I'll call Volk.

685. Ma'am, we have to put a tube

686. down your son's windpipe

687. so a machine can breathe for him.

688. Oh, my God.

689. Hold on, hold on.

690. No lung sliding on the right.

691. Pneumothorax.

692. No need to intubate.

693. What's going on?

694. He has a collapsed lung.

695. There was no history of trauma

696. that would have caused pneumothorax.

697. Glove up, Dr. King.

698. In asthma, you can get "air trapping."

699. When the lungs can't fully exhale,

700. eventually they overinflate,

701. causing some of the tiny air sacs to burst.

702. How do you fix it?

703. Like that.

704. It's a good thing Dr. Conley was here.

705. - Yeah. - We should probably try

706. to find him a Neuro-Critical ICU bed.

707. We don't want to board a patient like this.

708. - Mm-hmm. - Hey, Robby.

709. - Hey, how did the scan go? - Fine.

710. It is probably gonna take a little while

711. to get the results from the radiologist.

712. Well, that's not a problem.

713. Nurse Vivi and I need a little time

714. to coordinate our schedules over the next few months.

715. - Really? - Yeah.

716. I've always wanted to learn

717. how to ride a motorcycle,

718. and Duke offered to teach me.

719. Well, nobody knows motorcycles like Duke.

720. He's giving me the health care worker discount.

721. He's quite the gentleman.

722. Let's get him back to his room.

723. How would next Saturday be for you, Vivi?

724. Uh, maybe we could have some dinner after.

725. Dr. Mohan, Lorrie Diaz is here.

726. She wants to see her husband. She's heading back.

727. OK, I'm on my way.

728. Mrs. Diaz? - Hi.

729. Did Orlando go up to his room yet?

730. No. Um—

731. I brought him some dinner from Burgatory.

732. It's a chicken burger—

733. no bun, just lettuce.

734. Figured it would be better than hospital food.

735. He's being treated by our top brain-injury specialists.

736. Will he wake up?

737. We won't know for several weeks.

738. And then he could be back to normal?

739. Best-case scenario, it would take about a year

740. before he could be independent at home.

741. And the worst case?

742. Round-the-clock nursing care for severe disability.

743. You let him leave?

744. He insisted on leaving to work at his second job.

745. You couldn't make him stay?

746. He was competent. He knew the risks.

747. We honored his decision to leave.

748. Even if it was a stupid one?

749. I tried to stop him.

750. Offered to get him all the supplies he'd need

751. to take care of himself at home.

752. But he left before I could give them to him.

753. He said he couldn't afford to lose a paycheck.

754. Dr. Langdon.

755. Are you OK?

756. Yeah. I'm just kind of, uh...

757. wondering if I'm really ready to be back here.

758. Well, of course you are.

759. Ten months is a long time.

760. I almost killed that kid with an intubation.

761. Didn't even occur to me to check for pneumothorax.

762. There wasn't any trauma to indicate—

763. - I should have caught it. - OK.

764. You know, I, um...

765. I had a deposition today,

766. and all the lawyer's questions made me feel like

767. I was a really, really bad doctor.

768. We don't always get everything right the first time.

769. You would have caught the collapsed lung.

770. And it may have taken a minute, but you would have saved him.

771. I'm not sure Robby would agree with you.

772. He's been riding me all day.

773. Well, Robby's leaving for three months.

774. And, you know, with Robby gone...

775. I really don't want you to leave either.

776. That which does not kill me makes me stronger.

777. Wow, Friedrich Nietzsche.

778. Yeah, Nietzsche, yeah...

779. not Kelly Clarkson.

780. Hey, that's a thick one.

781. Yeah, Austin Green. Ogilvie's triple-A.

782. Uh, G-R-E-E-N?

783. Yeah. Why? What are you doing?

784. Checking to see when we'll get Ogilvie

785. back from the OR.

786. Oh, shit. - What?

787. The guy didn't make it.

788. He died on the table about 40 minutes ago.

789. Then where's Ogilvie?

790. Oh, man.

791. His patient had a CT a year and a half ago

792. that showed a 4-centimeter triple-A.

793. That's too small for surgery.

794. He was supposed to come back

795. every six months for a repeat ultrasound,

796. but looks like he didn't.

797. We would've seen that if the computers were working.

798. Why wouldn't he tell Ogilvie?

799. I don't know. Maybe he forgot all about it.

800. Or Ogilvie didn't ask the right questions.

801. Dennis, hey, got a minute?

802. Uh, sure. What do you need?

803. Teenager with jewelry magnets

804. stuck to both sides of her nasal septum.

805. I tried to move them with a plastic curette.

806. Too much pain, and then there was bleeding.

807. Those need to come off before they cause permanent damage.

808. Yeah, you think, uh, you could find, like,

809. a senior or an attending?

810. We're really trying to get off the clock here.

811. They're all busy.

812. I already took one for the team.

813. Yeah, fine.

814. Uh, labs on your yellow lady.

815. INR is elevated, 2.2.

816. Liver's in trouble but not dead yet.

817. Tell her to skip the turmeric.

818. Admit for monitoring, and follow the LFTs.

819. - Got it. - Mm-hmm.

820. - Central 10? - Yeah.

821. "Sleepmaxxing"? Really?

822. I track the online trends.

823. Is that your secret for the tough ones?

824. I just think,

825. what's the stupidest thing this person could have done?

826. Then assume they did it.

827. Well, I mean, she was trying to be healthy.

828. Yeah, by taking advice from fools.

829. Turmeric is recommended by a lot of doctors.

830. Yeah, then ask your doctor for the dose

831. or check someplace reputable, like the CDC.

832. Oh, right, I forgot, it's now a medical toxic waste site.

833. I mean, she's in pretty bad shape.

834. If things get worse, she could need a liver transplant.

835. Yeah, 'cause she's a big fucking idiot.

836. Wow.

837. No, I actually appreciate her.

838. Our job security depends on all these big fucking idiots.

839. OK.

840. Uh, good night, Perlah, Monica.

841. Good night, Dr. Robby. - Good night.

842. Bye, Emma.

843. You could stay to pitch in.

844. Mm, Dana told me to go and get some rest

845. before tomorrow's shift.

846. Yeah, you had quite a day.

847. Wasn't so bad.

848. Why can't I find Duke's results?

849. Oh, new patient, no EHR yet.

850. I can run over to Radiology, get a printout.

851. Thank you, Monica.

852. Ready to pick up a few more.

853. Orlando's all tucked in for now.

854. - How's he doing? - Numbers are good.

855. CPP 22.

856. OK, so he's got a shot at a decent outcome at least.

857. You think he has a chance?

858. Oh, I don't know that survival was

859. the outcome he was hoping for.

860. What?

861. He told Samira he's got $100,000 in medical debt,

862. that his life is probably— - Mrs. Diaz!

863. How can we help you? - The bathroom?

864. Uh, yeah. Perlah can show you the way.

865. Not a great idea to have a private conversation

866. about a patient in a public area.

867. I know. I know.

868. You were about to start yapping—

869. But I didn't!

870. OK.

871. And how long have they been in there?

872. At least two hours.

873. - How did it happen? - With my earring.

874. It was supposed to be, uh, red, white, and blue

875. to look cool at the fireworks.

876. I told her for the nose, one side only,

877. but she never listens.

878. This can be pretty serious.

879. If we don't get them out quickly,

880. it can cut off the blood supply

881. and cause the septum to collapse.

882. Like, my nose could be deformed?

883. Oh, my God, get them off. - Yeah, that's the plan.

884. Yeah, she tried already. It hurt like crazy.

885. Because they're stuck together

886. by a very strong magnetic force.

887. - Yeah. - No, no, no.

888. Oh, uh, I'm not gonna use the tips.

889. I'm gonna flip it around and use the handle.

890. It's still gonna hurt.

891. Probably not.

892. Just, uh, hold still.

893. OK.

894. Voilà.

895. - Really? - That was amazing.

896. I think another half hour,

897. we can send this dry-erase board back to storage.

898. With pleasure.

899. - Dr. Robinavitch? - Yep.

900. Results on your friend.

901. - Fuck. - Duke?

902. Are you gonna tell him?

903. I want to talk to a surgeon first.

904. Uh, Dr. Robby, I have an update on the patient.

905. Now is not a great time.

906. Oh, I thought you were going home.

907. Uh, I was.

908. Dr. Ogilvie is just sitting

909. out in the ambulance bay covered in blood.

910. Sorry, what— what's he doing out there?

911. Kind of, uh, staring off into space.

912. I tried to talk to him, but it was like

913. he couldn't hear me. - Monica,

914. can you stat page CardioThoracic?

915. - I'll go check on Ogilvie. - Please.

916. Oh.

917. Hey, Ogilvie.

918. Ogilvie...

919. y-you OK, man?

920. 99 on 2 liters.

921. Scattered end expiratory wheezes.

922. He is so much better.

923. The steroids should kick in soon.

924. So he'll keep improving.

925. Um, when can I go home?

926. In a day or two.

927. And we will, uh, discharge you with a Symbicort inhaler.

928. That should last about a month.

929. Hopefully we'll be back on Medicaid by then.

930. How'd you lose it?

931. They sent a redetermination letter to our old apartment.

932. It didn't get forwarded.

933. When I went to pick up his prescription,

934. pharmacist told me we were no longer covered.

935. And you haven't been able to get it back since?

936. I've been trying for months.

937. To get re-enrolled, you need tax returns,

938. pay stubs.

939. I cut hair. My income fluctuates.

940. A lot of my regulars are struggling,

941. so it's been tough.

942. Well, if you run out of Symbicort

943. before your Medicaid kicks in, you can come back,

944. and we'll, uh, set you up with another one.

945. Oh, is there a patient in here?

946. 'Cause everyone in this room looks extremely healthy to me.

947. Dr. Shen and I will be with Grady all night long.

948. Yeah. Day shift, we got this.

949. We're leaving you in good hands.

950. Um...

951. I was really scared.

952. Thank you.

953. You're very welcome.

954. Due to his injury, things have changed.

955. I was looking for Dr. Abbot.

956. I haven't seen him for a while.

957. Excuse me.

958. So now, with a long-term disability,

959. things may be easier.

960. "Easier"?

961. His condition will qualify him

962. for Medicare and Medicaid.

963. So, moving forward, costs should be covered,

964. including home health care.

965. OK.

966. Perhaps this isn't the best time—

967. I just wanted to reassure you

968. about future costs.

969. Robby.

970. Noelle.

971. You're still here.

972. It's not the best day to try to get out on time.

973. Mm.

974. So I guess this is it for a while.

975. Unless you want to come with me.

976. No, but thank you,

977. even if it isn't a legitimate offer.

978. - What do you mean? - Oh, please.

979. I know well enough not to get in between

980. a man and his vision quest.

981. "Vision quest."

982. That is my nice way of putting it.

983. I probably don't want to hear

984. your not-so-nice way of putting it.

985. No, probably not.

986. I-I hope that this is not, um...

987. about you running away from me.

988. I'm a big girl.

989. You can tell me just to get lost.

990. This has nothing to do with you.

991. Oh, right.

992. It's the old, uh, "it's not you, it's me"?

993. In this case, it's actually true.

994. Excuse me.

995. I'll see you next week?

996. It's a three-month sabbatical.

997. Like I said, I will see you next week.

998. My first day here as a med student...

999. there was a patient.

1000. He was a real nice guy,

1001. came in with belly pain.

1002. I saw a gall stone on the ultrasound,

1003. normal EKG, troponin.

1004. The pain resolved, and he was in the hall

1005. when he had a cardiac arrest.

1006. I couldn't save him.

1007. People die.

1008. And we do the best we can...

1009. but people die.

1010. You ever get used to it?

1011. No.

1012. No, you...

1013. you try to accept it.

1014. You try to find balance.

1015. I don't know if I can take another day like today.

1016. Primary care specialty sounds way better.

1017. Pedes, maybe.

1018. Yeah, maybe.

1019. I know I'd be bored out of my fucking mind.

1020. Seriously, I like the challenge of undiagnosed illness,

1021. of quick decisions, of life-saving procedures.

1022. And I like being here for people

1023. on the worst days of their lives.

1024. You know what I think?

1025. What?

1026. I think you should go home.

1027. I think you should sleep on it.

1028. And I think you should at least wait

1029. till the morning to decide

1030. if you want to come back.

1031. I don't really want to...

1032. go back in there and see anybody.

1033. Yeah.

1034. OK, pull off your gown. I'll take it in.

1035. Shift is over.

1036. Go home.

1037. - Oh! - Oh, God.

1038. - No, I'm—I'm— - Sorry.

1039. I'm good. I'm good. I'm good.

1040. There's a dummy in a wheelchair.

1041. Uh, yeah, he moves around.

1042. I see I've been replaced.

1043. Oh, did I take your spot?

1044. - Not really, no. - Are you sure?

1045. Where the hell have you been?

1046. I found Ogilvie.

1047. And?

1048. And he's going home.

1049. That's it?

1050. It's a long story.

1051. Well, I got nothing but time.

1052. I need to respect his privacy.

1053. Where's the fun in that?

1054. - Beep. Beep, beep. - Sorry.

1055. Um, the shredder jammed.

1056. Yeah, uh, try putting it in reverse.

1057. Perfect.

1058. Just give it a little love tap.

1059. - OK. - Kick it.

1060. Jesus Christ.

1061. Guess Mr. Digby got a room upstairs.

1062. In your dreams.

1063. He's not in South 21.

1064. Yeah, he is.

1065. There's a new guy in the bed.

1066. Short hair, clean-shaved?

1067. I'll take care of it.

1068. Scout film showed obvious pathology,

1069. so we ordered the CT angiogram.

1070. Textbook ascending aortic aneurysm.

1071. Eight centimeters.

1072. 50% one-year mortality.

1073. So he definitely needs surgery.

1074. If he wants to live.

1075. OK, well, he's a friend,

1076. so I will talk to him.

1077. I'll get him admitted to your service.

1078. - Not today. - Why not?

1079. He needs to see Cardiology and Pulmonary first

1080. to be cleared for the OR.

1081. They can do a stress echo, PFTs.

1082. He needs to be admitted and evaluated as an inpatient.

1083. Nothing ever gets done over a holiday weekend.

1084. He can take it easy at home.

1085. He's a ticking time bomb.

1086. He's probably been that way for years.

1087. We can get him in early next week

1088. with a specialist to get his testing done.

1089. All goes well, he's on the OR schedule in a week.

1090. What happens if it ruptures before then?

1091. Call 911.

1092. Sorry, Robby. Best we can do.

1093. Text me his number. I'll have my office coordinate.

1094. - Fuck! - Hey!

1095. Take a walk. Come on!

1096. Two for discharge.

1097. Yeah, please don't ring the bell.

1098. The computers are back up and running.

1099. Not for these two.

1100. They don't have electronic health records yet.

1101. Wait, hold up.

1102. This kid had a wrist X-ray ordered.

1103. Ugh, it never happened.

1104. And water-skiing lady's

1105. still waiting on a knee series.

1106. I canceled the X-rays.

1107. Diagnosed them both with ultrasound.

1108. Really?

1109. Yeah.

1110. The, uh, little boy had a simple buckle fracture.

1111. Distal radius. He got a Velcro splint.

1112. And Mrs. Stegman had a small medial meniscus tear.

1113. Knee immobilizer, crutches, and a follow up with ortho.

1114. Could have used you on the day shift today.

1115. They don't teach us a lot of musculoskeletal ultrasound.

1116. I know.

1117. That's why I did electives at Harvard and Highland.

1118. Are you applying for an ultrasound fellowship here?

1119. I am, but it is so competitive.

1120. - That's what I hear. - Kind of a long shot.

1121. I only have one publication,

1122. but it's a series of case reports diagnosing

1123. shoulder dislocations with ultrasound only.

1124. If you want to learn some MSK, you can tag along.

1125. I got three more to scan.

1126. Maybe some other time.

1127. Cool.

1128. Hey, don't jam the shredder.

1129. What is that, two charts?

1130. No, it's my ultrasound fellowship application.

1131. Hey.

1132. Uh, sorry about your patient.

1133. Yeah, Orlando's in pretty bad shape.

1134. Oh, no, I—I was talking about

1135. the triple-A guy you worked on with Ogilvie.

1136. He didn't make it through surgery.

1137. I tried to talk to Robby about it,

1138. but I think he's busy.

1139. Excuse me.

1140. Oh, shit.

1141. You think I'm on edge?

1142. First you're shaming Samira, then McKay—

1143. They both needed to be called out

1144. for unacceptable behavior. - Yeah?

1145. Yeah, well, you do that in private.

1146. Same place you share your thoughts

1147. about a patient's possible suicide.

1148. And slamming stuff? Please.

1149. Sign out all the shit that's bugging you

1150. and get out of here.

1151. - I can't. - Yes, you can.

1152. When either of my kids was acting like this,

1153. I gave them a time-out in their room.

1154. Whoa, whoa, whoa, you're not my mother.

1155. Yeah? Well, too bad.

1156. You need one. - No, I had one.

1157. She left. I don't need another one.

1158. What I need is someone who can actually run this place

1159. while I'm gone. - OK, I'm sorry.

1160. I didn't know. - Nobody knows.

1161. Who needs to know? Who gives a fuck?

1162. I think you need a break.

1163. That is what the sabbatical is for.

1164. Then start it now. Walk away.

1165. I have too much to do.

1166. Let someone else talk to Duke.

1167. No, that needs to come from me.

1168. Why?

1169. Because I owe him that.

1170. It needs to come from a friend, not a stranger,

1171. otherwise he's gonna bail and drop dead while I'm gone.

1172. OK, wrap that up and then leave.

1173. It's not just Duke.

1174. I'm not sure that Al-Hashimi is fit to run this place.

1175. - What's that supposed to mean? - I'm not sure.

1176. I'm trying to figure that out.

1177. Did you know that she wants to have two attendings

1178. on at all times? - No.

1179. Is that something she's worked out with Gloria?

1180. - I don't know. - I also don't know

1181. if Langdon is going to relapse.

1182. I don't know if Whitaker's gonna be able

1183. to take care of my shit.

1184. I don't know if Javadi's gonna give up on

1185. what she's good at or if Samira's gonna flame out

1186. because of some bullshit with her mother.

1187. - Is there anything else? - Yeah, you.

1188. I don't know about you running around

1189. with a full syringe of Versed in your pocket.

1190. I'm worried about the people that I care about.

1191. We'll all manage until you come back.

1192. We always do.

1193. Yeah? What if I don't come back? 35 —> 00:46:46,387 Yeah? What if I don't come back?