The Pitt 2x6

1. I'm in.

2. Bag him.

3. Defib pads are in place.

4. OK, holding compressions.

5. Good square line on the End-Tidal CO2.

6. V-fib, charge to 200.

7. Charged.

8. Clear.

9. Stand by with epi.

10. Suction that tube.

11. You're not in the esophagus, are you?

12. Definitely not.

13. I passed right through the cords.

14. Good breath sounds. End-Tidal CO2 confirmed.

15. His lungs are filling up with blood.

16. I know.

17. OK, rhythm check.

18. Asystole. Push the epi.

19. Fuck.

20. Patients with lunch trays have been admitted.

21. They're boarders.

22. They're waiting for a bed to open upstairs.

23. - And what about the others? - Non-admitted patients.

24. They can have sandwiches or juice boxes.

25. Just make sure they're not NPO.

26. That's "nil per os."

27. It's Latin for "nothing by mouth."

28. NPOs are waiting for surgery.

29. They'll beg, spit, and curse for food,

30. but you got to stay strong.

31. Hey, I've been waiting for an hour.

32. When am I gonna see a fucking doctor?

33. Excuse me!

34. Perhaps you didn't see this, which is strange,

35. because they're all over the place.

36. Aggressive behavior toward healthcare workers is a felony.

37. $2,000 fine, possible jail time.

38. Got it?

39. OK. I was just asking.

40. We're busy today.

41. It's a holiday weekend.

42. We see the sickest patients first,

43. so be happy you're still waiting.

44. Jag-off.

45. PTMC charge nurse.

46. Go ahead, Medic Command.

47. OK. Got it.

48. Incoming trauma.

49. Come on.

50. Three minutes since the last epi.

51. Hold compressions.

52. Asystole.

53. Resume CPR. Another amp of epi.

54. Needs more suction.

55. Pulmonary hemorrhage from liver failure.

56. Is he going to make it?

57. Should we give PCC?

58. Too late for that.

59. And he's not an ECMO candidate.

60. Nothing else we can do?

61. No, I think we're done.

62. Louie.

63. 12:07.

64. Should we do a debrief?

65. We've got another motorcycle injury coming in,

66. ETA 10 minutes.

67. Why don't we get Louie cleaned up,

68. move him to the viewing room? - Yeah.

69. Anybody that wants to pay their respects can join us in there.

70. Thank you, everyone.

71. I'll clean him up.

72. Why don't you take five first?

73. Or ten. Yeah?

74. Yep.

75. This is Dr. Jefferson from psychiatry.

76. Why do I need to see a psychiatrist?

77. Jada, why do I need to see a psychiatrist?

78. It's gonna be OK, Jackson.

79. Dr. Jefferson says he can help.

80. Do you know how you got here?

81. The medics brought me.

82. I don't really remember. I—I was in the library.

83. What were you doing there?

84. I was—I was studying.

85. I was trying to study.

86. But then they wouldn't stop talking.

87. Who wouldn't stop talking?

88. They don't want me to pass the bar.

89. Who doesn't want you to pass the bar?

90. - That's what they told me. - Hey, hey.

91. Hey, look at me. Look at me.

92. Who doesn't want you to pass the bar?

93. Let's give them some privacy.

94. Dr. Jefferson will let us know when he's done.

95. They don't want me to pass the bar.

96. I'll be right outside, OK?

97. I'll be right outside, Jackson.

98. Why don't they want you to pass the bar, Jackson?

99. They're afraid of me becoming a lawyer.

100. They're afraid of you becoming a lawyer?

101. He must have been studying with his law school friends.

102. They—they should know what happened.

103. I'm gonna call them.

104. If you need anything, let me know.

105. - OK, thank you. - Mm-hmm.

106. Louie.

107. Pulmonary hemorrhage.

108. That was quick.

109. I'm gonna go clean him up.

110. I'll help.

111. Go, go.

112. Everything OK, Roxie?

113. I can't get off the bedpan.

114. Oh, that's what I'm here for.

115. Your husband seems like a saint.

116. How long you been married?

117. Too long.

118. Almost 20 years.

119. - OK, put your arm around me. - Mm-hmm.

120. And I'll pull the bedpan on three.

121. OK.

122. One, two, three.

123. One more.

124. Great. - Mm.

125. 20? Wow.

126. Yeah.

127. He's been by my side through all of this.

128. I've watched the light go out of him.

129. So have the kids.

130. That's what happened to my auntie

131. when my Uncle Gerald got sick.

132. But your husband does it because he loves you.

133. Mm.

134. I don't know how you do it,

135. care for people day after day.

136. I'll tell you my secret.

137. I go home at the end of every shift,

138. leave this all behind,

139. and escape to "Love Island."

140. How's it going in here?

141. The higher-demand dose of morphine helped a little,

142. but she's still in pain. - OK.

143. I got your order. 0.1 per kilo.

144. - Thanks. - Mm-hmm.

145. This is a very low sub-dissociative dose

146. of ketamine.

147. You might feel a little weird,

148. but I think it's gonna help with the pain.

149. Is my husband still in the cafeteria?

150. I think so. Want me to get him?

151. No, no.

152. It's good for us to have a little time apart.

153. I'll get you another blanket.

154. Here. I'm headed that way.

155. Thank you.

156. Back here for good?

157. Officially out of triage.

158. They need extra hands with all the Westbridge hullabaloo.

159. How many cups have you had today?

160. - Don't judge me. - Just asking.

161. You're judging.

162. Did you hear about Louie?

163. No.

164. Pulmonary hemorrhage. Didn't make it.

165. - Shit. - Mm.

166. He's been here a hundred times.

167. I know.

168. Debrief in the viewing room later.

169. On a happier note, Perlah and I are planning

170. a birthday party for Javadi.

171. She's turning 21.

172. You two are thick as thieves.

173. I don't have much of a social life these days,

174. but I'll be sure to keep an eye out for the Partiful.

175. Let's discuss our incarcerated patient Gus.

176. Prison infirmaries tend to be short-staffed,

177. so we need to be thorough.

178. What's in the differential diagnosis for malnutrition?

179. Inadequate intake, methamphetamine use,

180. severe alcoholism, ADHD medication.

181. What else?

182. Cancer of the oropharynx, esophageal strictures,

183. prior strokes, malabsorption, inflammatory bowel disease,

184. none of which were in his medical record.

185. What about psychosocial causes?

186. Could be an intentional hunger strike.

187. Or refusing food to get to the infirmary.

188. Could also be abuse or neglect.

189. Let's start with a nutrition history once he's back from CT.

190. Do you have a second to talk about Westbridge?

191. Mm-hmm.

192. Hey, we need to start moving some patients out of here.

193. These walls are starting to fill up with gurneys.

194. Santos, Ogilvie, and King

195. all have patients on the launching pad.

196. I'll check in with them.

197. How many patients have we had rerouted from Westbridge?

198. Ten, and God knows how many more in the waiting room.

199. Ambulance will be here in a few minutes

200. with the accident victim; I'll stick him in Trauma Two.

201. What is the story with your incarcerated patient?

202. Gus Varney, three rib fractures

203. with normal O2 sats currently, waiting on CT results.

204. OK, if he's stable at the two-hour mark,

205. I'd say he's good to go.

206. Let's get the ball rolling on discharge.

207. Let's wait on the CT results.

208. We can move him out of Trauma One, at least.

209. Yes, we can. What's open?

210. 13 and 14 will be discharged soon,

211. 15 once we move Louie to the viewing room

212. and get it cleaned up.

213. Our paracentesis patient, Mr. Cloverfield?

214. V-fib arrest.

215. We'll do a debrief when we know how many patients

216. we're getting from Westbridge.

217. So Gus goes to 13, 14, or 15?

218. I kind of want to keep him in plain sight.

219. What about BH-2? - Sold.

220. Why not give him some privacy?

221. Everyone can see him in BH-2 like he's a monkey at the zoo.

222. Because he came in with an orange jumpsuit,

223. and we need to think about patient and staff safety.

224. Safety first. BH-2 beats a prison cell.

225. Not by much.

226. Did you guys hear about Louie?

227. - Yeah. - Yeah, chronic alcoholic.

228. Go figure.

229. Hey, fent OD in South 20 is ready for discharge,

230. but could you get Lupe to call him a ride?

231. I need to check on Louie.

232. - Uh, actually, Whitaker— - He croaked.

233. - What? - Five minutes ago.

234. Robby called it.

235. I'm sorry, man.

236. We didn't have time to find you.

237. What happened?

238. He was apneic and pulseless.

239. We started CPR and intubated him.

240. He had a massive pulmonary hemorrhage.

241. Robby called it.

242. Found this with his stuff.

243. Guess he was married at some point.

244. Never knew that.

245. Oh, didn't miss this part of the job.

246. Yeah.

247. Perlah, did Louie ever mention anything about a wife and kids?

248. Not as far as I know.

249. He only had eyes for Rita Moreno.

250. Well, this is not Rita Moreno.

251. No, it's not.

252. Can we check to see if there's an emergency contact?

253. Yeah, there's a number listed.

254. You were his primary. Do you want to...

255. No.

256. PTMC charge nurse.

257. Langdon? Where are you?

258. Makes sense that we'd be his emergency contact.

259. Sorry to get your hopes up.

260. Our social worker's gonna do their thing.

261. If Louie had any family left, they'll find them.

262. OK?

263. Guess it's good it happened here, not out on the street.

264. You're off the hook with Louie.

265. I'ma teach Emma here how to clean a dead body.

266. I'm sorry, but they need me in L&D.

267. You might want to call for another interpreter.

268. Busy day.

269. Shit, that's the girl in 12?

270. Yeah, she's been waiting for five hours.

271. Didn't hear her name called the first time.

272. You check on her?

273. Need to brush up on my ASL.

274. You know sign language too?

275. Princess here knows six languages.

276. - I know French. - OK, it's not a contest.

277. Ah!

278. No shit talking in front of me.

279. I get enough of that from her and Perlah.

280. Guess I'll call for backup.

281. Yo, Donnie, did you discharge your butt abscess?

282. Not yet!

283. What the hell?

284. Your good friends upstairs sent doughnuts.

285. Special thank-you for working the holiday.

286. You got to be kidding me.

287. What were you expecting, tacos and tequila?

288. Every single one of them can forget about extra shifts.

289. Won't hire more nurses. - Won't pay us a decent wage.

290. Won't hire security that can actually

291. protect us from patients.

292. But absolutely, send doughnuts.

293. Sure you want to go into this line of work?

294. Want me get you one?

295. Of course I do, but I'm not taking admin's blood pastries.

296. Et tu, Donnie?

297. OK, move it or lose it.

298. Meet me in South 15 with gowns and gloves.

299. Looks like happy hour in here.

300. Don't ask. What's up with Evel Knievel?

301. Brandon Li, 52, fell off a motorcycle pyramid

302. at 25 miles per hour.

303. Motorcycle pyramid? You recruiting?

304. Got a fellow rider in your midst.

305. - No kidding. - How high up were you?

306. On top of a three, two, one.

307. But the bottom guys are sitting down driving the choppers.

308. I'm fine. I don't need all this.

309. - Were you wearing a helmet? - Of course.

310. Oh, what do you know? They're still in style.

311. Good vitals, tender right wrist, and big left knee lac.

312. Hey, Joy, Perlah, Trauma Two.

313. Who else can I have?

314. Santos and Whitaker are in with Louie.

315. Yeah, give me Whitaker. He could use a distraction.

316. And Santos has been ducking traumas all day.

317. Well, she's behind in her charting.

318. Who isn't?

319. OK, even when it's not your fault,

320. sometimes it's worse knowing

321. that there was nothing you could do.

322. Uh-huh.

323. Are you—

324. Robby needs you both in Trauma Two,

325. and I need you to discharge sweet Patty in 13

326. as soon as you're done.

327. Can't catch a break.

328. I push you 'cause I know you can take it.

329. You ever clean a dead body?

330. Probably never seen one either.

331. No one tells you what it looks, feels, or smells like,

332. but you get used to it over time.

333. You pull off the gown. You wipe him down with towels.

334. Then we'll roll him on his side,

335. clean his back, stuff the sheet under him,

336. wipe down the bed, roll him the other way,

337. pull out the sheet, and repeat.

338. Just follow my lead.

339. Usually, you leave the ET tube in for the coroner,

340. but Louie's a chronic alcoholic with end-stage liver disease.

341. Not a coroner's case.

342. - Did he have family? - Everyone has family.

343. The social worker always tries to find them.

344. Sometimes the family loved them,

345. tried to get them to come home.

346. Other times, the family wants nothing to do with them.

347. - That's sad. - That's life.

348. What happens if no one claims his body?

349. He'll be cremated.

350. Where would his ashes go?

351. They'll keep him for a few months.

352. Then he gets buried in a mass grave

353. with all the other unclaimed bodies.

354. OK, now we roll him.

355. Ready.

356. Go.

357. Oh, my God, is he still alive?

358. No, that happens.

359. These frequent fliers.

360. They can be a real pain in the ass, but...

361. you miss them when they're gone.

362. I've been at every Millvale Fourth of July parade

363. since '08.

364. World record is 40 men on seven motorcycles.

365. I plan to beat that someday.

366. Good lung sliding bilaterally.

367. Pupils equal and reactive.

368. - What do you ride? - The Bullet.

369. Oh, Royal Enfield. Ankle breaker.

370. Thumper. - BP 138 over 80.

371. Pulse 94. Pulse ox 98.

372. All your vitals sound really good, Brandon.

373. They call it an ankle breaker 'cause

374. you got to kick over a big, fat single cylinder

375. to get it started, sometimes five or six kicks.

376. Yeah, especially on a cold day.

377. Um, does anyone have any trauma scissors?

378. I'll check the knee. - Uh, not yet.

379. - Why not? - Dr. Santos.

380. Primary survey means rule out the life threats.

381. Don't get distracted by lacerations or fractures.

382. No free fluid in the belly.

383. Airway, breathing, circulation are fine.

384. OK, that's ABC. That just leaves two letters.

385. Tell her about D, Dr. Santos.

386. Disability. Wiggle your toes, sir.

387. Any pain in your arms or legs?

388. Not really.

389. Does it hurt when I push here?

390. - No. - OK, no midline tenderness.

391. Nexus negative.

392. With no obvious brain injury or spinal cord injury.

393. That just leaves E. Joy.

394. Can I buy another vowel?

395. - Dr. Whitaker. - Exposure.

396. AKA strip and flip.

397. Cut off his clothes, and we'll log roll him.

398. What do we have?

399. Helmeted motorcycle acrobat.

400. 8-foot fall standing on top of five riders.

401. Primary survey normal, E-FAST negative.

402. Another motorcycle accident.

403. Hello, sir. I'm Dr. Garcia from surgery.

404. Hello.

405. OK, we will roll him in three, two, one.

406. Well, I grew up a block from Carrick,

407. but my mom was a teacher at Brashear, so I had to go there.

408. - The Bullets? - That's right.

409. They were the Bullets when I was there.

410. They changed to the Bulls when I left.

411. Oh.

412. Hey, you think I could get something to eat?

413. Gus here is wondering if he's clear to eat.

414. As long as it's a liquid diet.

415. We have the results of your CT scan.

416. Your jaw should heal without surgery, which is good news,

417. but it will be a few weeks.

418. Before I can eat?

419. Solid foods, yes.

420. Or you can have food pureed with liquid in a blender.

421. I don't have a blender.

422. Right.

423. Sorry.

424. We have a calorie-rich supplement drink called Ensure.

425. Comes in chocolate, vanilla, or strawberry.

426. Chocolate, please.

427. - Good choice. - How many can I have?

428. Two a day is recommended.

429. I'll get it for you.

430. You have an appetite. That's good.

431. Mr. Varney, your blood tests indicate

432. low levels of protein and vitamins.

433. Can we ask you a few questions about your diet?

434. How many meals or snacks do you have in a 24-hour period?

435. I don't know.

436. Don't count.

437. Pretty sure it's three trays a day.

438. OK.

439. How often do you eat cereals, fruits, or vegetables?

440. Not many fruits and vegetables in prison.

441. Slow and steady.

442. What year is your Bonneville?

443. '69.

444. Rescued it from a motor graveyard.

445. Brought it back to life with a buddy of mine,

446. who's supposed to be coming in today.

447. How often do you ride?

448. I ride it in to work every day.

449. Good for you.

450. Don't encourage him.

451. CT's ready for Brandon.

452. As soon as we take a look at this knee.

453. - Whoa. - Through the deep fascia.

454. How's it look?

455. Definitely gonna need stitches.

456. - How many? - A lot.

457. It could be an open joint.

458. We'll do a saline load after CT.

459. OK.

460. Lever sign negative. ACL intact.

461. OK, ready to roll.

462. Are you still coming over tonight?

463. I think Whitaker is gonna be playing

464. farm boy again this weekend, so he's not gonna be around.

465. I may need a rain check.

466. Hey, do you have an update on that nec fasc patient?

467. Last I heard, Miller was doing

468. an above-the-knee amputation with ortho.

469. Langdon's waitress with the cellulitis?

470. Yeah.

471. - Man, that took a turn. - Sure did.

472. Hey, did you hear about Louie?

473. - Yeah. - You OK?

474. Um,

475. one of my uncles drank himself to death.

476. I barely recognized him at the end.

477. At least Louie always seemed happy.

478. I'm here if you want to talk.

479. Should've known I'd find you in here.

480. You steal anyone's lunch, it's a $20 fine.

481. Made a lot of changes while you were gone.

482. I can see that.

483. Look, I'll let you hide out a little bit longer,

484. but then I need you to pick up more patients.

485. You're not as fast as you used to be.

486. Damn doughnuts!

487. Ouch.

488. First day back, I get kicked in the nuts.

489. One dead, one septic bounce-back.

490. Both of those not your fault.

491. You expecting a party?

492. No, not really.

493. Didn't hear from anyone while I was gone.

494. Sorry.

495. They ever, uh, arrest that guy who punched you?

496. Yeah.

497. Wanted to know if I wanted to press charges,

498. but didn't want to go through all that.

499. Thought I was done, really did, but...

500. I got bored at home, so only lasted a few weeks.

501. You?

502. 10 months is a long time to be alone with your thoughts.

503. I almost lost everything.

504. I know a lot of women who would have taken the kids and left,

505. but Abby stayed. - 'Cause she's a good woman.

506. 'Cause you deserve a second chance.

507. I'm not sure everyone agrees with you.

508. Give it time.

509. Look, I—

510. I, um—

511. I've been working the 12 steps, trying to make amends.

512. I was really selfish.

513. I lied to myself, and I lied to you.

514. I'm really sorry.

515. You can check me off your list, kid.

516. We're good.

517. - OK. - Yeah.

518. Got a lovely patient for you in Two.

519. Let's get you back on the horse.

520. Really need to talk with Robby.

521. I don't know if today's the best day for that.

522. He leaves on vacation tomorrow.

523. Let him get through the day in peace.

524. He's supposed to be gone for three months?

525. So he says. I give him one.

526. Go get 'em, kid.

527. Dr. Langdon, this is Rocky.

528. Great name.

529. What brings you in, Rocky?

530. Very sick.

531. When did it start?

532. An hour ago.

533. After he won a hot dog eating contest.

534. A hot dog eating contest? How many you eat?

535. 351 hot dogs?

536. 36.

537. Still a lot.

538. - I pulled eight of Zofran. - Go for it.

539. All right, this should help.

540. Stick it under your tongue. Let it dissolve.

541. OK, are you taking any prescription—

542. Oh, thank you.

543. Thanks.

544. Santos, what's up with your ileus patient?

545. Admitted to medicine, and before you ask,

546. 13 has been discharged.

547. Great. 12 needs a doctor.

548. No, don't make me go back there.

549. That disimpaction left a smell and stunk up the whole hallway.

550. So grab some coffee grounds from the lounge.

551. We need to admit our incarcerated patient, Gus.

552. What did the CT show?

553. Moderate pulmonary contusion, three rib fractures,

554. no intra-abdominal bleeding, and oblique fracture

555. in the body of the mandible anterior to the angle.

556. All favorable for healing. What's the treatment plan?

557. - A pain med— - Security.

558. People are trying to sleep.

559. Pain medication, antibiotics, liquid diet,

560. um, a pulse ox a few times a day,

561. and then also dressing changes for the laceration.

562. Which he can get at his correctional facility.

563. Or he stays here for a few days,

564. and we get him on the right track to healing.

565. Why don't you two go check on your patients?

566. - Got it. - Sure thing.

567. What am I missing?

568. He's not getting enough to eat

569. at his correctional facility.

570. The portions are tiny.

571. Too many carbs, not enough fruits or vegetables.

572. He's lucky he hasn't developed a chronic illness.

573. We don't have any inpatient beds.

574. He would board down here for three days.

575. We're still getting runs from Westbridge,

576. and we cannot tie up Behavioral for that long.

577. Dr. Al-Hashimi, Dr. Jefferson wants to talk

578. to you about our tasered kid.

579. Why don't I call the prison doctor

580. and find out what they're working with over there?

581. - Thank you. - My pleasure.

582. Dr. Jefferson seems to have a good rapport with Jackson.

583. That's excellent.

584. How's the sister doing?

585. Still pretty upset.

586. She's never seen him like this.

587. It's a lot to process.

588. How's he doing? - He's scared.

589. Droperidol had a positive effect,

590. but he doesn't understand what's going on.

591. He's been experiencing auditory hallucinations

592. and paranoid delusions.

593. Voices are telling him he isn't safe.

594. This has been going on for months.

595. - Months? - Yeah.

596. Turns out, his sister hasn't seen him in a while.

597. Family history of mental illness?

598. Not that we know of.

599. I'm gonna give him a break and then continue the conversation.

600. Parents are on their way.

601. We'll let you know when they get here.

602. Yes. Do.

603. OK, hospital bed, wheelchair,

604. and shower chair have all been ordered.

605. What do you say, kid?

606. Ready to go home?

607. How's your pain, Mrs. Hamler?

608. The same.

609. We're gonna write you a script for Keppra.

610. You'll take that to prevent seizures

611. once a day, starting tomorrow.

612. Between your broken leg and the bruises from your seizure,

613. the pain will probably get a little worse.

614. Yeah, the most important thing is

615. to let others help you.

616. You'll need assistance showering

617. and getting to the bathroom.

618. Yeah, no problem. I won't leave her side.

619. Paul, you need a break.

620. You're—you're taking care of me, the kids, the house.

621. It's too much for one person.

622. I'm not the one battling cancer.

623. Paul.

624. Hey, you're in pain every day,

625. fighting for your life.

626. I'm happy to do this for you.

627. You're my wife.

628. Now, let's go home and forget this day ever happened.

629. I'll call the transpo ambulance.

630. Thanks, Princess.

631. Hey.

632. Hmm?

633. Why don't you go ahead?

634. - What? - Yeah.

635. You can get the house ready.

636. I'll be right behind you.

637. - No. - Mm-hmm.

638. No, I'm—I'm riding in the back with you.

639. You know what? I'll stay with her.

640. Are you sure?

641. - Mm-hmm. - Yeah.

642. OK.

643. Um, call me if you need me to come back.

644. Mm-hmm.

645. When will the ambulance get here?

646. It shouldn't be long.

647. Mr. Francis, short of breath?

648. Yeah, I was worried the clot in my leg

649. could have gone up to my lungs, so...

650. You're on Eliquis. That shouldn't happen.

651. - Yeah, I know, but— - Hey, Donnie, I got this.

652. Don't worry, Mr. Francis.

653. I'll order the D-dimer. I'll be back to see you.

654. Thank you, Dr. Mohan.

655. You know I'm an NP now.

656. I can pick up a patient with dyspnea.

657. I'm sorry.

658. I've seen him before, and he's asked for me.

659. Why even order the test? He's on Eliquis.

660. Mr. Francis comes in every month

661. and always asks for a D-dimer.

662. Just—he's worried, and it puts his mind at ease.

663. Why not? - Yeah, OK.

664. Donnie's the best. You'll learn a lot from him.

665. That's right.

666. All right, fill me in.

667. This is Harlow Graham. She was seen in triage.

668. CBC and CMP came back normal.

669. IT was supposed to bring the VRI down, but they're slammed.

670. I know a bit of sign language.

671. Harlow, this is Dr. Santos.

672. Hi, Harlow. How are you feeling?

673. She has a headache.

674. OK. What else?

675. What is she saying?

676. I think she had a stomachache,

677. and she might have passed out.

678. I'm not 100% sure.

679. OK, we're just gonna need to wait for an interpreter,

680. 'cause I need to ask a million questions,

681. and I can't do it this way.

682. So just call me when IT comes down.

683. CT head, neck, chest, abdomen, pelvis all negative.

684. It means we can get this collar off.

685. Thank you.

686. Roll to your side.

687. We'll get you off this board.

688. How long is your trip?

689. 2,000 miles, all the way from here to Alberta.

690. Couple stops along the way.

691. Got the whole thing mapped out.

692. - Sounds like heaven. - Let's sit you up.

693. Sorry, I got stuck with a patient.

694. You know the old saying, four wheels move the body,

695. two wheels move the soul.

696. You're gonna be living the dream.

697. Thank you, Brandon.

698. Not everybody down here feels that way.

699. OK, Whitaker, what's next? - Ortho assessment.

700. Palpate all long bones, starting with the clavicle.

701. Got it.

702. I'll take the lower extremities.

703. Distal radius tender. No deformities.

704. Needs an X-ray.

705. No bony tenderness down here.

706. No laxity of the knee.

707. Are you concerned about that knee lac?

708. If it's an open joint, he'll need a washout in the OR.

709. We could try a fluorescein injection.

710. OK, we'll need a—

711. Wood's lamp, 1% lido with epi,

712. sterile saline, sterile basin, sterile fluoro-strip,

713. 18- and 27-gauge needles, 5- and 60-cc syringes.

714. How does she know all that?

715. She just does.

716. How are you feeling, Rocky?

717. Oh, much better.

718. He's had eight migs of ondansetron.

719. Any pain in the belly?

720. No, but my mouth is really dry.

721. No doubt from consuming mass quantities of salty hot dogs.

722. Could I have another sip of water?

723. Sure. A little sip.

724. Take it slow.

725. - Here you go. - Thank you.

726. Just enough to wet your whistle.

727. So how'd you get your start as a competitive eater?

728. Any pain here, Mr. Li?

729. - Can't feel a thing. - Great.

730. Where is Santos?

731. Probably catching up on her charting.

732. - Right. - Lights out.

733. Wood's lamp on.

734. OK.

735. I might want to use some of that on Halloween.

736. That is 250 ccs of sterile saline

737. with one small touch of a sterile fluoro-strip.

738. OK.

739. We're going to inject this fluid into your knee, Brandon,

740. and if there's anything glowing in your wound,

741. we know we have a leak.

742. - Feeling some pressure. - Yeah, it's normal.

743. As soon as I finish the test, I'll pull off the fluid.

744. That looks good.

745. Laceration did not enter into the joint space.

746. Surgery not needed.

747. Excellent. I can get back to the parade.

748. No, we'll still need to

749. stitch you up and splint your wrist.

750. Hanging a gram of Ancef.

751. Wait, he has a penicillin allergy.

752. No, PEN-FAST was negative. We're OK.

753. My mom said I got a rash with amoxicillin when I was two.

754. Yeah, probably not a true allergy.

755. Go ahead and give it, Kim.

756. But have epi and Benadryl standing by, right?

757. Yes, to be on the safe side.

758. Most people who think they have a penicillin allergy

759. actually don't.

760. Always listen to the nurses. They run the ER.

761. We just try and stay out of their way.

762. Now we can really clean him up.

763. Didn't we already do that?

764. Dried blood on the face, neck, hands.

765. If anyone comes, they shouldn't have to see that.

766. Sometimes the local unhoused folks will pay a visit,

767. but we always make them presentable

768. in case anyone comes.

769. That's the last thing we can do for them.

770. Didn't get to do that during COVID.

771. Once he's spotless, we'll tuck him in nice and tight,

772. but we always leave one arm outside the sheet.

773. Because?

774. So loved ones can hold their hand.

775. Here you go. - Thanks.

776. Yeah.

777. We're ready to discharge our cancer mom, Roxie.

778. Ambulance is on the way; we just need

779. to reconcile her home meds. - Sounds good.

780. Hey, I thought I saw another charge nurse around here.

781. Oh, yeah. We travel in packs.

782. Aren't you sick of this place yet?

783. Oh, someone is ready for his sabbatical.

784. Guilty as charged.

785. Hey, I just got word that the at-home morphine pump

786. is gonna be delayed.

787. Hospital pharmacy has to mix it

788. and then deliver it later today.

789. Well, should we keep her here until it's ready?

790. No, you can give her

791. a 200-milligram tablet of MS Contin.

792. - 200 milligrams? - Biggest pill they make.

793. Releases over 12 hours for patients with opiate tolerance.

794. Got it.

795. Hey, do you want to stick around a little bit?

796. Westbridge is closed to internal disaster.

797. We're getting all their runs. - Yeah, I heard.

798. I put 20 bucks on a plumbing issue.

799. I just watched that poop cruise documentary.

800. Oh, I cannot stop thinking about it.

801. That sounds like something I will absolutely never watch.

802. Dr. Robby,

803. you gave us a clozapine ileus about an hour ago.

804. Your resident reported no surgical history,

805. but the chart says they've had an appendectomy.

806. We're not admitting the patient without a surgery consult.

807. - Who called it in? - A Dr. Trinity Santos.

808. Dr. Santos, you had an ileus patient.

809. You neglected to mention a history of appendectomy.

810. There was no history of appendectomy.

811. It was in your note.

812. I may have forgotten to proof check it.

813. I was using the app that Dr. Al-Hashimi suggested

814. to catch up on my charting.

815. Wonderful.

816. Ah, Dr. Al-Hashimi. - Yes?

817. Dr. Santos was just using your AI tool for her charting,

818. and it hallucinated a history of appendicitis.

819. As I mentioned to Dr. Santos, generative AI is not perfect.

820. We still need to proofread every chart it creates.

821. Mm-hmm, the patient also has a history of headache,

822. followed by Dr. Park from Urology.

823. That should probably be Neurology.

824. Unless urologists are now treating migraines.

825. Another example that should have been caught

826. by proofreading.

827. AI's 2% error rate is still better than dictation.

828. Yeah, I don't really give a shit whether or not

829. you want to use robots down here.

830. I need accurate information in the medical record.

831. - Understood. - OK.

832. Dr. Santos.

833. Dr. Santos!

834. Yup. Won't happen again.

835. Hoy.

836. Thanks, Perlah.

837. Six hours to go. You got this.

838. When a wound is gaping like this,

839. you want to use sub-Q to bring the edges together.

840. A lot of meat to close.

841. What would happen if we just did a simple wound closure?

842. You take the stitches out in ten days,

843. the wound opens, dehisces.

844. Exactly.

845. So what suture do we use under the skin?

846. Vicryl provides support for a month.

847. It takes two months to dissolve.

848. Mm-hmm. So 5-0 nylon on the skin.

849. 4-0 vicryl under the skin.

850. I'd go with a 3-0 vicryl.

851. - You think? - Most definitely.

852. Donnie is the master of wound closure.

853. I do at least ten lacs a day out at triage, so...

854. Can we see your sub-Q?

855. Be my guest.

856. If you insist.

857. So...

858. The secret is to be sure your entry point

859. and exit point on both sides of the wound

860. matches the depth on the other side.

861. S—

862. Start deep.

863. Come up at the dermis.

864. Big bites help the tissue close.

865. It's a mirror image on the other side.

866. Superficial to deep.

867. - So you bury the knot. - Bingo.

868. Avoids bumps on the scar line.

869. Three ties, not four.

870. Yeah, that's beautiful.

871. And then you cut it short.

872. Not too short.

873. I like to slide my scissors

874. down on the knot,

875. then rotate up 45 degrees before I cut.

876. Could use two more sub-Qs,

877. one above, one below.

878. Have at it.

879. Interesting ink. Do they mean anything?

880. This, this is "death and chaos,"

881. and this is "miracles and blessings."

882. Got this one after the PittFest shooting,

883. and I got this after my daughter was born.

884. Put the head of the gurney up

885. so people can see him, but not so high

886. that his head flops to the side.

887. What do you think?

888. He looks peaceful.

889. What's the hardest part of this job?

890. It's pretty thankless, and that can be tough.

891. You've seen burnout rates.

892. I'm sure they teach you that in school.

893. All my closest friends left after COVID.

894. Some during.

895. But I don't blame them.

896. They needed to do what was best for their mental health.

897. A lot of people broke.

898. Why do you keep coming back?

899. Why don't you, um,

900. just finish up here and then go help Perlah for a bit?

901. Great. Thank you.

902. No, that is exactly what I needed to know.

903. OK.

904. I just got off the phone with the physician assistant

905. at the prison; they've got a 16-hour-a-day infirmary

906. with NP and PA coverage giving everything that we need,

907. and they've got an RN for overnights.

908. Even so, he's here because

909. they're ignoring his basic needs.

910. He's here because somebody kicked the shit out of him.

911. I think you're missing the point.

912. We have more to offer.

913. Robby, we've got four more coming our way.

914. OK, got it.

915. What you're trying to do is very noble.

916. We don't have the resources to spare.

917. OK, then why admit the unhoused man, Digby?

918. Why not send him back to the street

919. with antibiotics and a roll of gauze?

920. Because Digby lives on the street,

921. and your incarcerated patient has a mid-level provider

922. and a nurse looking after him.

923. We both know the quality of care is not the same.

924. Sorry, are you waiting for me?

925. No.

926. Dr. Al-Hashimi, for the patient in Seven.

927. A few days here could make a world of difference

928. for Gus' health.

929. We are a safety net, but nets have holes.

930. We are not admitting him

931. 'cause this is not about social justice.

932. Everything I've done in my career

933. is an effort to improve the system.

934. Just because you know it's broken

935. doesn't mean you stop trying.

936. Excuse me.

937. I talked to Jackson's girlfriend.

938. OK.

939. She told me a lot of stuff.

940. Um, she wants to come see him,

941. but I just don't think that's a good idea.

942. And my—my parents are asking a lot of questions.

943. Can I just take him home?

944. I'm so sorry.

945. Your—your brother is on an involuntary psych hold.

946. He can't leave.

947. It could take us weeks to figure out

948. what's wrong with him.

949. What's wrong with him?

950. I'm so sorry. I did not mean it like that.

951. What's—

952. Why don't we go somewhere quiet, yeah?

953. What's wrong with him?

954. - Let's go over here. - What's wrong with him?

955. What's wrong with him?

956. What's wrong with him?

957. How's she doing?

958. She took three ounces of formula

959. without vomiting or distress.

960. Excellent.

961. Dr. Wolke from Pedes should be down shortly.

962. Yeah. I think I saw her smile.

963. A true social smile where the baby is awake, alert,

964. and responding to facial expressions

965. usually doesn't happen until six weeks or older.

966. It was likely a reflex smile that happens

967. while they're sleeping.

968. But some parents have reported their babies

969. smiled socially as early as four weeks,

970. so who knows?

971. - Jesse. - Hmm?

972. North 4 needs a blood draw when you have a sec.

973. Got it.

974. How we doing in here?

975. Almost ready to head out.

976. Looking good.

977. Heart rate 91.

978. BP is 115 over 82.

979. Oxygen sat's 95%.

980. Great.

981. I'm sending him home with some nonstick dressing

982. in case they don't stock them.

983. Grab some burn net too.

984. He's a good guy. He's a local.

985. Yeah? You're from Pittsburgh?

986. Yes, ma'am. Born and raised.

987. Whereabouts?

988. Bloomfield, Liberty Ave.

989. Bloomfield?

990. You know Sonny's Tavern?

991. Worked there through high school.

992. - No kidding. - You know Sonny's?

993. Had my first kiss there.

994. Hey, Donnie, my buddy Duke hasn't checked in yet?

995. Nah, I told Lupe to keep an eye out.

996. - Thank you. - Yep.

997. Right, left. Right, left. Yeah. That's it.

998. You back to check our work?

999. Nope. I need a silastic loop drain.

1000. That looks great.

1001. It's thanks to your fine instruction.

1002. OK, he's going to need Kerlix and Xeroform.

1003. You should throw a neoprene sleeve on him.

1004. Limits the range of motion at the knee

1005. so the sutures don't pull out. - That's a good idea.

1006. Must be fun to work here.

1007. Oh, sure is. First week for these two.

1008. How are you guys liking the Pitt?

1009. I feel like I was born to do this.

1010. Hard pass.

1011. I'm shooting for pathology.

1012. I like medical mysteries,

1013. but I don't really deal well with people.

1014. You have an interesting energy.

1015. What's that for?

1016. Splint starts at the knuckles,

1017. comes up and around the elbow,

1018. and back down to the palm.

1019. It needs to be smaller. I can't ride with a splint.

1020. Well, no, you shouldn't be riding at all.

1021. Right now, that's a non-displaced fracture.

1022. If you fall on it again, you're gonna need to go to the OR.

1023. No worries, Doc. I won't fall again.

1024. Uh-huh.

1025. Robby, pulse ox just dropped.

1026. What happened?

1027. I don't know. I stepped out for a minute.

1028. It's down to 85%.

1029. Are you having some trouble breathing?

1030. A little.

1031. Start him on 2 liters oxygen, nasal cannula.

1032. Titrate to 5.

1033. Keep the pulse ox at 92 or higher

1034. and have a rebreather standing by just in case.

1035. He's gonna have to stay.

1036. For how long?

1037. Not sure.

1038. Sorry, boss, I only stepped out for a second.

1039. Let me know if anything changes.

1040. You were in the room when his pulse ox dropped?

1041. - I was. - What were you doing?

1042. D, still can't get a hold of Ortho.

1043. Leave them to me.

1044. - Feeling better? - Oh, so much better.

1045. Well, I wrote you a script for Zofran, just in case.

1046. Thanks. I think I cleared it all out.

1047. - So no more hot dogs, right? - Oh, not today.

1048. But I'll be back next year.

1049. Got to defend my title! - Yo.

1050. OK, well, best of luck to you.

1051. They got a Wiener World truck outside.

1052. You want one?

1053. I think I'm good on hot dogs for the rest of my life.

1054. Wait, didn't I just see you eating a doughnut?

1055. Don't judge.

1056. Stay here for a sec.

1057. Transport ambulance is here. - Thanks, Princess.

1058. This is a 200-milligram MS Contin.

1059. This will give you 12 hours of relief.

1060. OK. - Mm.

1061. Yes.

1062. Whenever you're ready, Rox.

1063. Hey, guys, this is Roxie Hamler.

1064. Hello, ma'am.

1065. - Easy on the transfer, guys. - Yeah.

1066. OK, on my count.

1067. No, no, no. This isn't gonna work out.

1068. I'm sorry.

1069. I can't—I can't—

1070. I can't—I can't do this.

1071. - It's OK. - I want to stay.

1072. Please.

1073. It's OK.

1074. Can I assume that you've already called upstairs

1075. to get Gus Varney a bed?

1076. Do you want to tell me what you did?

1077. I don't know what you're talking about.

1078. His pulse ox was steady. We were about to discharge him.

1079. Did Dr. Al-Hashimi put you up to that?

1080. Al-Hashimi? No.

1081. You know he's gonna go back to prison

1082. after they discharge him upstairs.

1083. I thought you didn't go the extra distance

1084. for your patients anymore.

1085. - It's Emma, right? - Yeah.

1086. How's your first day going?

1087. Good, I think.

1088. Haven't killed anyone yet.

1089. I'm sorry. I— - It's OK.

1090. I guess time will tell if I'm cut out for this.

1091. Well, when in doubt, stick with her, kid.

1092. She scares me.

1093. No, that's just a— it's a tough exterior.

1094. She's warm and gooey on the inside.

1095. Looks like they're doing the debrief for Louie.

1096. - You coming? - I paid my respects.

1097. Besides, who's gonna hold down the fort?

1098. Remember the day you found him passed out in the park?

1099. Sure do.

1100. I had to drag his ass over here.

1101. Came in soaked to the bone.

1102. You saved his life.

1103. How about last summer when we didn't see him for months?

1104. He said he finally quit drinking,

1105. so he didn't need to come in. - Mm-hmm.

1106. How many times did he say he was gonna quit drinking?

1107. Mm-hmm.

1108. He always asked about Harrison.

1109. - Always said thank you. - Mm-hmm.

1110. Found this with his stuff.

1111. Who knew he was married?

1112. Hmm.

1113. That's Rhonda, Louie's wife.

1114. High school sweetheart.

1115. About five years ago, I was covering a night shift.

1116. He came in feeling talkative.

1117. Born and raised in Pittsburgh.

1118. Lifelong Steelers fan.

1119. Groundskeeper at Three Rivers Stadium

1120. until 1998.

1121. He never really wanted kids,

1122. but Rhonda wore him down,

1123. and when she finally got pregnant,

1124. he changed his tune, he got excited.

1125. And then about a month before the baby was due,

1126. Rhonda and the baby were killed in a car crash.

1127. Louie never really came back from that.

1128. May his memory be a blessing.

1129. - Amen. - May his memory be a blessing.

1130. Yep.