[muffled indistinct chatter]
[tense music]
[indistinct chatter continuing]
- Robby.
♪ ♪
Robby. [tense music stops]
College kid in respiratory distress is here.
- All right. [clears throat] - You OK?
- Yep. [inhales deeply]
I wanted to talk to the patient in Central 12's son,
but he took off.
- Is there a problem?
- Uh, according to Mom,
she found a list of high school girls
that he'd like to eliminate.
- What's wrong with kids these days?
- Uh, you mean besides social media
and the worldwide pandemic and the environmental crisis?
- Yeah, yeah, yeah. - And gun violence?
- You're a fucking fountain of hope today, aren't you?
- Nick Bradley, 19, found unresponsive by parents.
No meds, no allergies.
On arrival, he was barely breathing
with pinpoint pupils, bradycardic at 38.
Pupils responded to Narcan,
but we tubed him when his respirations didn't pick up.
- Any drugs or alcohol on the scene?
- No. - Signs of trauma?
- Nothing.
- OK. Open your eyes, Nick.
On three. One, two, three.
- Where was he found? - In bed by his mom.
- Pupils are 6 millimeters, non-reactive.
- Heart rate's 64. BP is cycling.
- No response to pain. GCS 3.
- Does that fit any toxidrome? - No.
If it was just opiates with Narcan,
he'd be breathing on his own.
- Uh, beta blockers shouldn't get pinpoint pupils.
- Maybe parents had some
prescription meds in their bathroom.
- They're on their way.
- Code trauma, tier 1, ETA five minutes.
- That's a stand-up scooter rider versus car door.
No helmet. - No blood in the belly.
No pericardial effusion, and lungs are up.
- Hemocue's good, 15.
BP 84 over 58. - OK.
What's your plan, Dr. Collins?
- Um, push dose epi, 0.1 milligram.
Foley for urine, stabilize for CT,
and throw a wide net.
[vitals monitor beeping]
- Where-- where are we going now?
- We need the room for someone else,
but you can rest in the hall till we get your labs back.
- Your parents must be proud.
Having a son for a doctor.
- Yeah, I guess.
Um, you know,
I was the first one in my family to go to college.
You know, they sacrificed a lot to get me here.
How's your pain, Mr. Milton?
- Uh, I'm fine.
Could use a latte, though.
- That could bring back the gallstone pain.
- How about a bourbon?
- [chuckling] It's barely 8:00.
Uh, how about some ice chips?
- [chuckling] No, thanks.
I prefer my whiskey neat.
- [sighs] Yeah, that's not happening.
- [chuckles]
- [chuckles softly]
- Systolic back down to 90.
- Another 0.1 of epi.
- Flaccid paralysis of all four extremities.
- [exhales] No eye movement with ice water.
- So no brainstem function.
- Due to?
- Hypoxic injury, massive hemorrhage.
Samira, escort him to CT.
Take the drug box with you.
- Call me if you need me.
Hey, are you OK?
- Yep. - Are you sure?
- Have you ever had to worry about me?
- No, but it never hurts to check in.
It's part of my job.
- Consider yourself checked in.
- OK.
Ah, ah, ah, ah, ah.
Got something?
- Oh, I had a case for Dr. Collins.
- May I see? - Yeah.
A 68-year-old male, history of hypertension,
one hour of right upper quadrant pain
after eating a fatty meal, now resolved.
Afebrile, non-tender.
There was a gallstone present on POCUS.
EKG shows no acute ischemic changes,
but I'm still waiting on LFTs and lipase.
- Why did you order the EKG?
- The nurse suggested it to rule out any cardiac issues.
- Well, good call on both your parts.
Nurses know what they're doing.
Never hesitate to listen to them.
Come find me when those labs are back.
Hey, how's that finger? - Oh, it's nothing.
- Dr. Robby? - Yep?
- The son and daughter of Mr. Spencer
from assisted living, they're here.
- OK. I'll be right there.
[glove snaps]
[indistinct chatter]
[sighs]
Your father has pneumonia and a condition called sepsis.
- What is-- what is that exactly?
- It means that the bacteria has spread from his lung
to his bloodstream.
So far, he's been responding well to treatment.
- Hey, Pop.
It's Helen and Jereme.
- [sighs]
- Jereme...
Hillary...
Boob...
[chuckling] Fud.
- [chuckles]
It's the "Nowhere Man" from "Yellow Submarine."
It's what he used to call me when I didn't do my homework.
- Is this his baseline?
- He has good days and bad days.
- Why don't we step out for one more second?
So your father came in with low blood pressure,
which is improving.
- Can he go back to assisted living?
- Eventually, we hope so.
Your dad has an advanced directive
expressing his wishes, which says that
IV fluids and medications are OK,
but no artificial life support, no CPR.
- He doesn't want a bunch of machines keeping him alive.
- OK.
Then we will continue with oxygen
and IV fluids and antibiotics,
but if his lungs stop working,
we're not going to place a tube in his windpipe
for a breathing machine.
- But pneumonia is treatable?
- Most of the time, it is.
- But if he can get better in a week,
then put him on a machine.
- That's not what he wanted.
- Do either of you have durable power of attorney
for health care?
- Yes. - We both do.
- OK.
Well, this is a decision
that does not need to be made right now.
Why don't you think about it?
Talk about it.
If things get worse, sometimes allowing
for a comfortable natural death can be the most humane path.
- No routine cases until we assess the tier 1.
Thanks.
- Dr. Langdon?
- So, uh, how was the VA?
- Yeah, it was, uh good, uh, you know, challenging.
I learned a ton. I just think it--
maybe it should be mandatory
that all doctors spend time there,
like, on a regular basis
because of all they've sacrificed for us.
- That's a nice thought. Why'd you choose the Pitt?
- Oh, I have a sister with special needs
and she got into this really great facility
here in Pittsburgh.
And PTMC has such a great reputation,
I thought, you know, it'd be a good fit.
- Can I present my headache to you?
- Uh, yeah, what do you got?
- A 36-year-old woman with severe headache
due to paracervical trigger point.
Her pain went from 11 to zero after 2 ccs of IM Marcaine
to the-- - Wait, wait, wait.
You did a trigger point injection
before presenting the case? - Yeah. I--
- Interns always present first.
- I spent a month at the pain clinic at Hopkins.
- No, it's not OK. - Incoming!
- I'm very comfortable with-- - It's definitely not OK.
- 23-year-old Ben Kemper, no helmet,
got doored riding an e-scooter.
Neck versus handlebar then face-planted to the pavement.
Obvious facial fractures,
but alert and oriented with good vitals.
- Here we go.
One, two, three.
[elevated vitals monitor beeping]
- How are we doing, Ben?
- [strained] Blood, back in my throat.
- That's probably from the nosebleed.
Short Rapid Rhino, please.
- Tachy at 120, pulse ox borderline at 90.
- Blow by at 15 liters for now.
- Neck contusion. - BP 138 over 84.
- Larynx shifted to the right, no crepitance.
- 4 of morphine.
I'm going to stick something in your nose to stop the bleeding.
- No hemotympanum.
- Inflate the balloon.
- How about now, Ben?
- [softly] Better. - What's up?
- Good vitals, A and O, let's have a look.
- [gagging]
- Ouch.
- Floating face. - Le Fort III fracture.
- You don't see that every day. OK, let's prep for airway.
Double setup just in case.
[indistinct chatter]
[sighs]
[door clicks]
- Nice work. - Thanks.
- All right, Mr. Tagari, you are good to go.
- Oh, thank you.
Remember, 10% off for doctors and nurses.
- I'm a student doctor.
- Oh, right. Sorry. [chuckles]
I hit my head, remember? - Well, my son loves pizza,
so I will take you up on it for sure, OK?
- Thank you. Thank you. - Thank you.
Wait for a nurse. - OK, thanks.
- [whispers] Hi.
I just realized it sounds like I always feed my kid junk food.
- Oh. - You know?
Pizza, s'mores.
- No, no, please. I--I like pizza and s'mores.
Who doesn't? - Mm.
How many kids do you have? - Just one, Harrison.
He's 11 now.
- What does your husband do?
- No husband, just me and my son.
I take it you don't have kids?
I--I don't mean on account of your age.
Or maybe I do.
I mean, most medical students don't have kids.
- Oh, yeah, no, no. Um, no kids.
Just not even a boyfriend. Uh, it's just school for now.
- Yeah. That'll keep you pretty busy.
I do not miss it.
- Must have been difficult as a young mother.
- It had its moments,
but my life has been full of challenges,
and med school was not one of the hardest, by far.
It was one of the most rewarding, though.
Other than having my son. - Hey.
Facial lash with possible foreign object in the eye,
which is always a solid 7 on the WMMV Scale.
What Makes Mateo Vomit.
- [laughs]
- You OK? - Yeah.
Yeah. Um, he's funny, the...
the nurse. - Oh, Mateo.
You can say his name.
- Um, yeah, uh...
a foreign object in the eye could be really serious.
- [clears throat]
- Hey, Fruitcake.
Hey, I'm talking to you, Fruitcake.
- Myrna, I told you a hundred times
my name is Dr. Robby.
- You want to see my vagina?
- I have already seen it.
And once was enough, thank you.
- Robby, parents of Nick Bradley,
the OD teen, are here. - OK, park them in Trauma 1.
He's not back from CT yet.
I'll be right there in a minute.
- Got it. Behaving yourself, Myrna?
- Oh, yes, ma'am.
- How we doing?
- Ketamine and sux on board.
- Pulse ox holding at 94.
- Prepping the neck just in case.
- Let's have a look.
[steady beeping]
A little deeper.
- Lots of swelling. I can't see the cords.
- To the right. The left.
Yeah, it really distorted from the trauma,
and the edema's only going to get worse.
- Which is why we should crike.
- You don't crike a laryngeal fracture.
Don't listen to Edwina Scissorhands here.
If they can't cut it,
surgery doesn't know how to fix it.
- The contusion is high at the thyroid cartilage,
so you just stand there looking pretty, ER Ken,
and let me fix this.
- We're down to 85. - All right, pull out.
I-gel, bag and crike. - I-gel, please.
[rapid beeping] - Turn off the alarm.
- I've never done a crike before.
- No. Mel will do the crike.
You've already had a busy morning.
Glove up, Mel.
- No, I'm doing the crike, doctor.
- You would be doing it, doctor,
if it wasn't an odd day.
Surgery gets even days, ED gets odd days.
You know this. For crikes' sake.
- That's because you're all fucking odd down here.
- OK, team work, please. Let's focus on the patient.
- I so appreciate your gracious understanding.
- I'll assist in case she screws up.
- Yolanda, play nice.
- Sats are up with the I-gel.
- You ready? Hello?
- Oh, uh, hello.
- You've done this?
- Yes, in the cadaver lab.
- Let's hope that's not where this poor soul ends up.
We'll do an open technique since we have a minute.
- OK.
OK, you're going to be making a vertical incision
to avoid the jugulars in the carotids.
[steady beeping]
Mm-hmm, good.
If this was a crike that needed to happen in seconds,
you could use a 10 blade, your finger, and a bougie.
[ventilator whooshing]
[vitals monitor beeping]
- This is called a Weitlaner.
And this is your trake hook.
- C-spine, head CT, OMF. Start a propofol drip.
OK, now we're going to make a horizontal incision
across the cricothyroid membrane.
Yeah.
- 4.0 Shiley next.
Get ready to bag the crike.
Yeah, yeah, yeah, good.
[vitals monitor beeping]
- Oh, excuse me.
- No worries.
- End tidal CO2 is yellow.
- Yellow is yes. Nicely done.
Sew it in. OK, I will be next-door.
[sighs]
- Does your resident know how to suture,
or do I need to teach?
- You're all class, Yoyo. - I know, thanks.
That means a lot of nothing coming from you.
- Mel, you OK? - If you're done fighting.
- We're not fighting. This is playing.
Langdon's too soft to fight.
- Oh, yeah, I have nothing but respect for Dr. Garcia.
In fact, I think she would
make a wonderful hostess at Applebee's.
- Later, Odds.
- Let's go.
- OK, thanks.
Just received word your son's head CT is normal,
and he's maintaining a good heart rate.
- You got him back. - Thank you. Thank God.
- Right now, he's unconscious
with a tube in his throat for oxygen.
Why don't we step out for a minute while they
get him settled, and then you can come back?
You can sit with him as long as you want.
- Nicky, it's Mama. I'm here, baby.
- You're doing great, son.
- Blown.
- OK, let's step outside. - OK.
[indistinct chatter]
- [sighs]
So we don't know
how long he was at home without breathing.
- He's breathing now. - Not on his own.
- But he's going to wake up.
- We certainly hope so.
We're going to know better after
we get some more test results back.
Are you sure that he didn't take anything
that could have caused this?
- No, no, he's a good kid.
He's in college, he has a part-time job.
He even chose to live at home so he could focus on school.
- Dr. Robby. From the urine.
- What's that?
- It's a drug test.
And it is positive for fentanyl.
- No, that is impossible. Nick doesn't do drugs.
- There are a lot of pills that are sold illegally
that have fentanyl, not just painkillers.
Xanax, Ativan.
- No, not our son. - Uh--
- Well, maybe he didn't know that he took something
with fentanyl, I don't know.
The hows and the whys don't really matter.
What matters is spending time with Nick.
We've got some more tests to run.
We'll know our options after that,
but in the meantime,
why don't you take a seat and talk to him?
- Can he hear us?
- You know, we're never really sure,
so we should assume that he can.
And we'll come find you as soon as we know more, OK?
- OK.
[vitals monitor beeping]
- Can we move Nick Bradley to a private room?
- The kid going to make it?
Didn't he respond to Narcan?
- I think his pinpoint pupils just grew into blown pupils
from brainstem death.
- Shit. - Yeah.
Not much older than Jake.
- Don't go there.
[alarm beeping] - Hard not to sometimes.
- Mr. Spencer's room.
Hey, Robby,
Theresa, the mother of the young man David who bolted,
she's asking for her son.
- OK. I'll be there in a minute.
- What is happening?
- Uh, his oxygen levels are dropping.
Mr. Spencer, how are you feeling?
- I don't remember where I parked.
- Mr. Spencer, do you know where you are?
- It's so loud in here.
- Dad? Do you know where you are?
- Dad, look at me. What's my name?
- [sobbing] I don't know where my car is.
- BiPAP, 15 over 5.
Let's step out.
- What's a BiPAP?
- It is a pressurized air mask that can improve his oxygen.
Either his pneumonia is getting worse
or his heart couldn't handle the fluids
that we gave him to treat the sepsis.
His lungs are filling up with fluid.
- Can't you take the fluid away?
- Not without his blood pressure crashing
with very bad consequences,
so let's just hope the BiPAP works.
- And if it doesn't?
- Then I would need to know your decision
about using a breathing machine.
- We're still talking about it.
- Well, we know he expressed his wishes.
In writing. "Do not intubate."
- We're thinking try it for a week.
- That would be a very painful week.
He wouldn't get a lot of rest with all the monitors
and all the blood tests. He might need to be sedated.
He might need to be restrained
because he'd be in an unfamiliar place
with a very uncomfortable tube down his throat.
And he wouldn't really know what was happening.
Elderly patients can often develop psychosis.
- But he might get better. - Or he might get worse.
What would you do?
- I really can't answer that for you.
This is your father. It's your decision to make.
I can guarantee you
that we will keep him as comfortable as possible
if a natural death is what you choose.
- But he's not your father.
[shakily] And he can recover from this.
- What my sister means
is that we're still deciding the best thing to do.
- Well, the sooner you decide, the better.
I'm really sorry.
I wish there was more that I could do.
I'm not sure that he has that much time left.
- [gasps]
- Dr. Robby.
- You were right.
She can't say whether she was bumped by accident
or shoved on purpose. - No other witnesses?
- No, not really.
We pulled security footage. Maybe we'll find something.
Hopefully she tripped.
I don't mean I hope she tripped.
I mean I hope she wasn't pushed on purpose.
- That would this a hate crime.
- Yes, ma'am.
- Ma'am? - Doctor.
Sorry. I'm--I'm sorry.
- [laughs] No harm, no foul.
- Will you let me know if she says anything else?
- Will do.
- At the risk of seeming--
- Then you probably shouldn't.
- I just-- - No, trust me.
- How do you know-- - I just know.
- I just wanted-- - I know.
Look, I'll let you know if she says anything else
that could be important to your investigation.
- Thank you.
You know, for the record-- - Nope.
- [chuckles]
- Any luck getting our psych boarders upstairs?
- Yeah, right, at least the Kraken's still sleeping.
- Is it me or was that officer--
- No. - What?
You don't even know what I-- - What you were going to say?
- Maybe you do.
He seemed nice. - Absolutely not.
Mm-mm.
There is no possible scenario
in which you and I have this conversation.
You of all people should know better.
- I was-- - No.
Just walk away.
Best possible scenario. Just keep on walking.
Mm-hmm.
- You got to lay off mixing Adderall and energy drinks.
- Trust me, I will.
- [chuckles] All right. Thanks.
That's the thing about emergency medicine.
You never know what you're going to get.
And we get everything.
- Is that why you chose it?
- [sighs] Maybe a little.
I also get to pick my shifts,
which, for a single mother, is amazing.
But mostly, I just like the people, you know?
They're always there when you need them.
Who wouldn't want to be a part of that, you know?
[alarm beeping]
[softly] Fuck off.
[sighs]
- This is the monitoring center.
We see that you are not in your inclusion zone.
Do you have permission to be outside this area?
- Yes, I am at work.
Just like last time and the time before that.
[alarm beeping]
[sighs] I'll be right back.
[alarm echoing]
What is the point of this fucking thing
if it doesn't even work?
[sighs]
[beeping alarm echoing in hallway]
- Sorry.
- You're doing great. Take your time.
You OK?
- I am--yeah.
I get frustrated when I can't do things,
or at least it looks like it.
- Yeah, you and me both.
- Thanks, but my frustration manifests itself emotionally,
and then, uh, I get upset,
and then it looks like I can't handle things,
and, you know, then I can't cry in front of the patient
because no one wants to see their doctor cry.
That's just a big red flag.
- You just did a perfect crike. You're doing great.
- Hey, you! Pasty white!
How about a sandwich?
- Uh, what brings you here today, sir?
- I'm here for a fucking sandwich.
- OK.
OK, uh, excuse me...
- Perlah. - Perlah.
Can this patient get a sandwich?
- I already gave you a sandwich, Earl.
- I ain't ate this whole week.
- [chuckles] Sure.
Give him another sandwich. They're on the food cart.
Just make sure it's not egg salad,
or he'll throw it on the floor.
- OK. Good to know. Thanks.
- Any quick ones up here?
It's only 8:30, and Robby's already on my case
for being too slow.
I can usually at least make it to lunch
before he starts hounding me.
- Cut him a little slack today, OK?
It's the anniversary of Dr. Adamson's death.
- That's sad.
But it's still no reason to take it out on me.
I'm just saying.
- Dr. Mohan? - Samira, please.
- I just wanted to apologize.
When my phone went off earlier, that was really unprofessional.
- Don't sweat it. Trust me.
We need to laugh.
Otherwise, we'd never stop crying.
- Thank you.
- Besides, with all the craziness
that comes through here every hour,
nobody cares or notices. - [sighs]
- Got an unresponsive unhoused man coming in.
Might be a good teaching case, Funky Music.
Let's go.
- Caucasian male,
approximately 60 to 70 years old,
found unresponsive. No signs of trauma, no ID.
- On three.
One, two, three.
Oof. Did you take anything?
- I smell the alcohol from here.
- This guy's wearing the spring, summer,
and fall collection.
[scissors rustling]
[rat squeaking] Oh! Whoa!
- Jesus, uh-- - Oh, oh, oh!
[rats squeaking] - What the--
- Oh!
- Uh, what's wrong? What's going on?
- Patient tested positive for rats.
- No.
- If it matters, I only counted three.
Oh, there goes one.
[clattering] - [laughs]
- Because your son tested positive for THC,
the psychoactive ingredient in cannabis,
we're going to have to admit him for overnight
observation and monitoring.
- And what about his brain?
Is there a chance that much pot is going to do some damage?
He's only four.
- The honest answer is we don't know.
There haven't been any long-term studies,
but the fact that this is a one-time occurrence
suggests that there should be no long-term effects.
- But you don't know.
So my son could end up with learning disabilities,
psychiatric problems, or even autism because of this.
- There's no evidence to suggest any of that.
- Hello. I'm Kiara Alfaro.
I'm the department social worker.
- Kiara will help you navigate the next steps.
- What steps?
- Well, a case like this
requires mandatory reporting to child services
and sometimes law enforcement. - No.
- Why--why do you have to involve the police?
- It's a controlled substance.
- They're not taking my kid away.
- They were pot gummies. - No one's suggesting that.
- Well, fuck your suggestions! No one is touching my child!
In fact, we're leaving.
- Well you-- no, you can't take your son.
He could stop breathing. He could have a seizure.
- I will observe him at home. - Amanda, please.
- Fuck off, Drew. - Get security.
If you can't cooperate,
I'm going to have to ask you to leave.
- Amanda, please. He needs to stay here.
- And you need to get a fucking hotel.
- Your son can't leave the hospital,
but I can have you removed.
- Don't you dare touch me.
Get out! All of you!
- Mrs. Jones, I know this is scary and stressful.
- Oh, fuck you! Fuck you! This is my son.
My son! And nobody is touching him!
- Whoa, whoa, whoa. What's going on?
- How can I help you? - By backing the fuck off!
- Mom's worried a CYF investigation.
- Amanda, just calm down! - OK, OK, OK, enough!
This is a hospital.
This isn't "The Jerry Springer Show."
Ma'am, nobody's trying to take your child,
so why don't you stay here with him
while your husband talks to our social worker outside
and straightens all this out?
- Well, I don't want him speaking for me and my son.
- Well, it is either you or him.
Your son is not leaving, but you can be escorted out
and even arrested if you refuse to cooperate.
Nobody wants that.
So you tell us. What do you want to do?
- I'm staying with my son. - OK, great.
You do that.
We all on the same page here?
Thank you, Olsen.
- You know where to find me. - You OK?
- Yeah, we got this.
- All good. - It's all yours.
- Mrs. Jones, we just have a couple things.
[indistinct PA announcement]
[indistinct chatter]
- Everything all right out there?
- Yeah, just another day in paradise.
How are you feeling? - Better.
Where's David? - He left.
He said he had to get back to school.
- [sighing] Oh.
- Um, maybe you could try calling him,
get him to come back.
- What's going to happen to him if I do?
- Hopefully he'll be willing to talk to somebody.
- Will you talk to him? - I can try.
I don't think he wanted to talk to me.
Have you shared with anyone
about the writings of his you found?
- No.
I didn't know who to tell.
I just don't want to see him get hurt.
- Neither do we.
- [sighs]
It's just going straight to voicemail.
- Maybe if you can text him.
[phone chirps]
- He's not texting back.
Oh, I'm sorry about all this.
- It's OK, it's OK.
What are you doing for David is very brave.
- I'm his mother.
I'll do anything to protect him.
- Do you think he would hurt anyone?
- No.
But...
I'm sure a lot of parents felt that way
before their children did unspeakable things.
- Does he have any history of violence?
Has he ever been in any trouble?
- No, never.
He's very quiet.
And he takes great care of me.
He--he's struggled with his father's death.
We both have.
- Flight is ten minutes out with an electrocution.
- OK, grab Collins. I'll be right there.
Keep trying to reach him.
If you do, have someone come find me.
OK? - OK.
Thank you. - Of course.
You got some good news for me? - I sure do.
There are two rooms in ICU being cleaned.
They'll be ready by now. - Great.
- And I got bagels in the lounge.
- Nice job. Thank you.
[sighs]
- Is it true? - You have to be more specific.
- Are there rats in the ED?
- Uh, apparently, if somebody already snitched.
- Do you know how bad this looks?
One more reason to shutter this place.
Only the emergency department admits rats.
- Emergency department would never admit rats,
unless they had the right insurance.
- Did you catch any of them?
- One, and I charged him for a full visit.
- I'm glad you think this is funny.
- I'm sorry that you don't.
- Did you call an exterminator?
- He's waiting on a second opinion.
- [shuddering chuckle] You're pushing your luck today.
- Don't worry. Last I heard,
they were headed for the cafeteria,
so they should be dead within the hour.
- OK. - [groans]
I'll be here all week. - Or maybe not.
- [screaming]
- Drug-seeking woman kicked off the city bus
for disrupting and disturbing passengers.
- I called 911!
- She's been screaming for narcotics nonstop.
We found an empty Percocet bottle filled five days ago.
- What are you doing? What are you doing?
- She's been uncooperative
and combative since we picked her up.
- Get off her. Let her go.
- Stop fighting. - [screams]
- Calm the fuck down, or I'm calling the cops.
- My meds at home aren't working!
Please, I have sickle cell!
- OK, stop. Everybody stop.
Stop!
- [screams] - What's your name?
- It's Joyce. It's Joyce St. Claire.
- Joyce, is this your sickle cell pain?
- Yes! - 10 milligrams of IV morphine.
- You really want 10? - Yes.
Repeat it in five minutes if needed.
And she needs a Dilaudid drip.
This is a vaso-occlusive crisis!
I'm so sorry this happened.
You're going to be OK now.
- [sobs] - You're safe here, I promise.
Come on.
You're going to be safe here. I promise.
Just breathe. OK? - [exhales deeply]
[helicopter whirring]
- Live wire hit his left forearm,
shocked him once for v-fib.
- Was there a power pole down? - No, abandoned factory.
We found bolt cutters at his side.
- Got electrocuted.
- Was he trying to steal copper?
- Most likely.
Powerline fried his arm,
and the current through his whole body stopped his heart.
- Ready?
Steady, lift.
Add a myoglobin and a CK to the labs.
Two liters normal saline wide open.
- Dr. Santos, what are we worried about?
- Um, rhabdomyolysis from tissue damage
can kill the kidneys, ongoing risk of cardiac irritability.
- Excellent. - AP pads in place.
- Guy fell off a telephone pole?
- No, he was on a platform. - Boring.
- Cut into a live wire.
- Tense ventral compartment.
- Set up the STIC pressure monitor.
[steady electronic beep] - V-fib.
- All right, charge to 300. - Charge to 300.
Am I running this or are you?
- Sorry, reflex response. - Clear.
[defibrillator thumps]
[electricity snaps] - Ah, fuck!
- Sorry.
Sorry. - [shudders]
- So what--what happened?
- [whispering] I bought it for my girlfriend's dog.
I work nights, and he yaps all day long.
And when I woke up, I was wearing it.
Stupid bitch!
[electricity snaps] [whimpers]
- Sorry, sorry.
- I think she must have used Krazy Glue.
- Yeah, it, um, it looks that way.
Have you tried removing the batteries?
- Of course. She glued the case shut.
- All right, I think we have a couple options, Gary.
Um, we can try to find a solvent that will dissolve
or at least soften the glue enough for you to peel it off
without taking your skin with it.
Or, um...
Dr. Javadi? - Um...
I--I guess your skin cells on your neck will naturally
slough off and you should just be able to remove it in time.
- How much time? - Um, couple of weeks, maybe.
- Couple weeks? [electricity snaps]
- I think this guy's got scurvy.
- What is he, a pirate?
- No, he's an unhoused man
who lives almost exclusively on dollar store ramen.
There's perifollicular hemorrhage, gingivitis,
bleeding gums, and, um, yeah,
no fruit or vegetables in his diet.
- I suppose that could do it
as long as you've ruled out piracy.
No parrot, no peg leg, doesn't reek of sweat and rum?
- Well, now that you mention it, there was a smell.
- Probably a pirate.
Tell him to pick up some vitamin C
next time he docks at a dollar store.
- I can't tell if you're joking.
- No, Captain Scurvy's got a vitamin C deficiency.
Cheapest way to fix it is with a daily supplement.
- Captain Scurvy is another joke.
- I'd like to think so. - It's a good one.
- Dr. Langdon, Dr. King, this is Arthur Carlson
from Children, Youth, and Families.
He'd like to speak to the parents of Tyler Jones.
- Right, right.
Uh, Mel, would you mind showing him to Kiara and the family?
- Mm. Yeah, right this way.
- Beto? - Hello, Doctor.
- What are you doing here? - I'm working day shifts now.
- Didn't you retire a couple of years ago?
- No.
I have to work today. - Right.
Right. Just stay right here, OK?
- I--I have a lot of cleaning to do.
- Yeah, no, I'll be just one second.
- Hey, Doc, Doc! How about a sandwich?
- Sure, Earl. Turkey, no egg salad.
I got you. Just give me one minute.
[indistinct chatter]
So Beto said he's working here?
- Yeah, he just started wandering.
Fortunately, he always winds up back here.
He thinks he still works in the ED.
I called his family.
They usually pick him up after a few hours.
- Really?
- Yeah. It gives them a break.
And look at him. He's talking to people,
feeling useful, getting some exercise.
Hell, I wish I was that happy.
- You think he's any good at catching rats?
- Stop. - Oh, Earl wants a sandwich.
- He always wants a sandwich.
- Hey, check it out.
I got my kids a puppy.
- Cute. Hope that wasn't your idea.
- Why? - Seriously?
You really think your wife
needs anything else to take care of?
- Abby loves dogs. - I love penguins.
It doesn't mean I want to take care of one.
- I'm pretty sure it's illegal to own a penguin.
- Pretty sure you're missing the point.
- The point is Tanner promised
he would take care of it.
- A four-year-old? Yeah, OK.
[indistinct chatter]
[vitals monitor beeping]
- How's she doing?
- Still breathing after 20 of morphine.
- How's the pain, Joyce?
- [groans] A little better.
- We've ordered an exchange transfusion.
- Mm. Figured I needed that.
- What's your normal regimen at home?
- 90 of extended-release morphine every 12 hours
and oxycodone for breakthrough pain,
but it wasn't working.
- Starting IV Dilaudid of four an hour.
You can press this button if you need a little extra.
- That only works once an hour, though, so don't go crazy.
- Could I confer with you? - Yeah.
[indistinct PA announcement]
- You seem surprised by the opioid dosage.
- It seemed a little high. - So was her pain.
- How do you know she's not drug-seeking?
- You can't fake a hemoglobin of 6.
Do you know what sickle cell crisis does to the body?
Blood cells get caught and plug up your capillaries
and deprive all your cells of oxygen.
It's been described as an electrical stabbing pain
that feels like it's breaking your bones
and flushing glass through your body.
- I never thought of it like that.
- Little empathy goes a long way
with those suffering in real pain.
- Yeah. - Don't worry.
You'll get good at spotting the fakers,
and half the time, all those people need
is someone to really listen to them and hear their story.
- [softly] Mm-hmm.
- Interior compartment pressure is 49.
- Burn caused massive swelling.
- What does he need, Dr. Santos?
- Fasciotomy, but he still has a radial pulse.
- Pressure would have to be over 100 to lose the pulse,
and at that point, he'd lose the arm.
- 49 is enough to destroy all the nerves and muscles
in a matter of hours.
- Compartment pressure's 49? - Yeah.
I'm going to make the initial incision down here.
Ortho can finish it up in the OR.
- Good plan. I'll let them know.
Hey, Robby. - Always good to see you, Fred.
- How do you like my rock star? - She's pretty good.
both: She has a great teacher.
- Sterile gloves for Dr. Santos.
- Oh, we don't teach forearm fasciotomies to our residents.
- What if she's all alone somewhere someday
with no backup?
This is the path to avoid the median nerve
and all major vessels.
- Maybe just watch the first time.
- She'll hold the blade, I'll cut.
10 blade to Dr. Santos.
We'll start proximal.
- How much pressure?
- Just about this much.
Mm-hmm.
Through the skin and sub-Q.
- Good.
[indistinct chatter]
- How they making out?
- They're still talking.
- You OK? - Yeah, for sure.
I just--I hate seeing families torn apart.
- Oh, they'll be fine.
- How can you be sure? - They're white.
Probably get off with a slap on the wrist.
If they weren't, she'd probably lose her child
and he'd end up going to jail, but...
Sorry, I did a fellowship in cynicism.
You sure you're OK?
- 100%. I'm just going to get some air.
I am a savage, classy, bougie,
ratchet, sassy, moody, nasty.
I am a savage... [tires screech]
- [groans] I need help!
I got shot.
- Can you guys help?
[tires squealing] What's your name?
- Alex.
- OK, Alex, let me take a look.
- It fucking hurts.
- Oh, I know. All right.
We're going to take good care of you.
- Yeah. - You guys got it?
- Let me get you up here, Alex. - [groaning]
- I got you.
- I have an abdominal GSW
in the ambulance bay, code trauma now.
- GSW just got dumped by a homeboy ambulance.
- You got this? - Yeah, go.
- 2 grams of Ancef. Ortho's on their way.
- Systolic's only 80. 14 gauge left AC.
- We got two units of whole blood
going on the rapid infuser.
- Call the OR. We'll be right up.
Lungs up.
- Do you take medications every day?
Any allergies? - No.
- Morrison's is full of blood. You see that?
- Yeah. - Tore up his liver.
- What's his name? - Alex.
- Alex, you've lost a lot of blood.
You need to go to surgery right away.
- Am I going to die?
- Not now that I'm here.
- Spoken with the humility of a surgeon.
- OR's ready. How's he doing?
- BP is coming up a bit. - Let's go.
- Can you call my mom? - Yep.
- She's the "ICE" on my cell. - Of course, of course.
- So he didn't have to wait for an OR?
- No, we're a trauma center.
We always keep one OR stocked and ready to go.
- [chuckles] Well, that's awesome!
What--what happens if there are multiple traumas needing OR?
- We get a lot busier.
- Mr. Milton, I'm sorry.
We had to move you into the hall.
I know it gets pretty chaotic and noisy out here.
Mr. Milton?
Hey, hey, Bennet, wake up for me.
Oh, shit, shit, shit. Um, I need a little help here!
Help!
- When did you check on him last?
- I don't know, around half an hour ago at most.
I was waiting on labs. - What's going on?
- It's my gallstone guy. You saw his EKGs.
- Unknown downtime. He was sleeping in the hall.
Crash cart, let's go!
[tense music]
- I got it.
♪ ♪
- Hold compressions.
[defibrillator beeps]
Asystole.
- Resume compressions, amp of epi.
- Slower, slower tempo, slower tempo.
- Should I intubate? - No. Drop an LMA.
We don't want to hold compressions.
- Pupils are fixed and dilated.
- He's been down a long time.
- How we doing in here?
- So much better.
Dr. Mohan, this is my wife, Ondine.
- Dr. Samira Mohan. Nice to meet you, Ondine.
- Thank you for helping her. - Of course.
And, again, I'm so sorry about how you were treated
when you first arrived.
Not everyone who works here
is accustomed to dealing with sickle cell.
We will be doing everything possible
from here on in to manage Joyce's crisis.
In the meantime, can I get you anything?
- I'm fine.
- Ondine? - No, thank you.
- OK. Well, have the nurses come find me
if you need anything.
- Take slow, deep breaths for me, Ian.
- They ordered a neb, 5 albuterol, 125 solumedrol.
- All right.
Keep an eye on him and present to Dr. Langdon.
- OK. - OK, great.
I'll see you back in triage once he settles down.
- Yeah.
OK, let's take this off.
All right, hang in there, Ian.
This should really help your asthma.
- How can I help you, hon?
- Um, I'm looking for Dr. Langdon.
- Yeah, let me see where he is.
Dr. Langdon, we have a med student
at Central looking for you.
Copy that. He's headed this way.
- Thanks.
- Hey, Crash.
You missed a pretty cool fasciotomy.
- I'm not sure I'd be describing
a fasciotomy as cool.
- You would if you were the one who did it.
How's it going out in the arrivals lounge?
- Do you know anything about Dr. McKay?
- I've been here for less than two hours.
I don't know anybody, including you.
I thought you were some kind of kid genius.
- I'm like any other third-year med student.
- Clearly. [chuckles]
Hey, I'm just trying to break the ice.
I'm not trying to annoy you.
- And yet, you're still calling me Crash
when I asked you not to.
- Really? You're still on that?
- Still on that.
- [sighs] Yep. OK, sorry.
I had no idea genius was so sensitive.
But I get it. Big brain, big feelings.
Makes total sense.
I'll try to be softer.
- [speaking Tagalog]
- [chuckles]
[speaking Tagalog]
[vitals monitor beeping]
- We switch out every few minutes.
You can take a break. - I'm fine.
- Hold compressions.
[flatline tone droning]
- Still in asystole.
- Resume compressions.
- Should we shock him?
- You don't shock asystole.
- It could be fine v-fib.
- Not a chance. - OK.
Uh, when was his last epi?
- Three minutes ago. - OK.
Well, ACLS says every three to five minute, right?
So let's push another round. - Fine.
- Robby, Mr. Spencer's adult children are asking for you.
And the parents of Nick Bradley,
the fentanyl overdose, also want to speak with you.
- OK.
Three rounds of epi and then call it.
- Mr. Spencer's maxed out on BiPAP, 25 on 10.
- Sats? - Not great, High 80s.
[indistinct chatter]
- Hi. I heard you wanted to talk to me.
- Yeah. That alarm kept going off.
- Yeah. Why don't we step outside?
[clears throat] The alarm is for low oxygen.
- Does he need more of that, um, BiPAP?
- I'm afraid that's as high as we go.
So the decision at this point is--
- We want you to put our father on the breathing machine.
- Even though that goes against his desires
to not be intubated?
- We're not ready to let go yet.
- And if your father is?
- He was a stubborn son of a bitch
who would never have given up on either of us.
We're not giving up on him.
- You're absolutely certain you want
to put your father through this after everything I've told you?
[sighs]
I may have to honor his advanced directive.
- No, you have to honor our durable power for health care.
If not, we can talk to your hospital attorney.
- Jereme, you're on board with this?
- Yeah, I guess so.
- OK. You can sit with him until we're ready.
- And when will that be? - Momentarily.
[indistinct chatter]
- Please don't tell me
you're going to intubate that poor man.
- It's what the family wants.
- So what? They want to torture him?
- I explained all that.
- If I co-sign, you can override their durable power.
- They're threatening to go to the hospital attorney.
- Let them. Call the Ethics Committee.
They'll agree with us.
- No, no, you're probably right.
But we don't have that kind of time.
We are stuck.
- What are you talking about? - Shit.
- What?
- I got to go tell those parents
their 18-year-old son is brain-dead.
- Want me to come with you? - No, It's OK.
- What are you going to say?
- I'm going to say that it's likely,
but we still need to do an apnea test
and a cerebral perfusion study.
- There's no cranial nerve activity.
- Those people need some hope. - False hope.
- Hope is hope. - Is it?
What, are we praying for miracles today?
- They need time to process
before they can accept what's happening.
- You ever consider taking that advice?
Physician, heal thyself.
- Don't you have patients?
[inaudible]
- No, no, no, no, no, no. People wake up from comas.
You can wake him up.
You can do that. You can--you can shock--
you can-- you can shock him back.
[sobbing]
Nick.
[crying]
- Hey, hey, hey.
[softly] Hey, hey, hey, hey, hey.
- [sobbing] Nick.
[crying]
Please, no!
[sobbing]
[vitals monitor beeping]
[flatline tone droning] - No change.
- No pericardial effusion,
no tension pneumothorax, no cardiac activity.
- Try calcium. Could be hyperkalemia.
- No, his potassium was normal.
- Ready to call this? - Not yet.
Dr. Robby said three rounds of epi.
It's time. Let's push another amp.
This one could do it.
- OK.
- [panting]
[tense music[
♪ ♪
[soft dramatic music]
♪ ♪
[upbeat music]
♪ ♪