Is it true?
Simi told Hector that Dr. Deranjian said
the hospital was up for sale.
They might turn it into an ortho center with no ER.
Oh, they're always threatening to shut us down,
but they never do.
Do you believe him?
I never trust the doctors.
Gloria is looking for you.
No guts, no Gloria.
Must be time for my weekly spanking.
Try to be nice, for all our sakes.
You sure you're cool being here today?
Yeah. Why wouldn't I be?
Well, if you need to talk…
Yeah, I won't, but thanks.
Where's Abbot?
Getting some air.
Hey.
You OK in there?
Uh, awesome.
I'd like to say it goes away, but I had morning sickness
for six months with my second daughter.
Hell, who am I kidding?
That one still worries me sick.
- Thanks. - But it's worth it.
You tell anybody yet?
Oh, no.
Not until I pass 12 weeks. Not this time.
Nothing but good vibes.
But just so you know, Robby's working today.
Today's the day Doc Adamson died.
He hasn't worked it in four years.
So why is he here?
All I know is, he still blames himself
for Adamson's death, so if he's a little prickly today,
give him a pass, OK?
- Right. - Thank you.
Hang in there, kid.
Good morning, Jack.
What are you doing here?
I'm working.
And you?
Oh, I don't know.
Had a guy come in.
Hit by a drunk driver in a crosswalk.
39-year-old vet.
Survived three tours without a scratch.
I spent the last two hours coding him.
That's always a rough way to end the night.
I must have had a reason
at one time to keep coming back,
but I can't think of it right now.
Because this is the job that keeps on giving.
Nightmares.
Ulcers.
Suicidal tendencies.
Besides, if you jump on my shift,
that's just rude, man.
I hope I'm never one of your patients.
That makes two of us, my friend.
I got a pregnant teen coming back today for mifepristone
and a small bowel obstruction waiting on surgery
for the last three hours.
Oh, and unfortunately,
the Kraken is still boarding in BH.
Still?
Guy's been here for a week waiting on a psych bed.
Yep. He's only getting worse.
He's catching some Zyprexa Z's at the moment.
But when he wakes up, God help you all.
I wrote a note for the family of my dead vet,
if anyone shows.
Oh, and you got the med students
and new interns starting today, so good luck with that.
Lucky, lucky me.
- Sir, come back here! - No more needles!
- Oh! - Sir!
- No more needles! - Stop!
Sure you want to work today, huh?
Help me! They're gonna hurt me!
Sir, I promise nobody is going to hurt you.
Sir!
Who left this mess?
They had a rough night.
Good morning, sunshine.
You obviously haven't seen this board.
Oh, we've seen worse.
Nothing like a little challenge every now and then
to keep everybody on their toes.
- Dr. Robinavitch? - Yep.
Melissa King. I will be joining you today.
I just came from two months at the VA.
Hey, welcome to the Pitt.
This is Dr. Jack Abbot.
Nice to meet you.
I can't tell you how excited I am to be here today, so…
Talk to me at the end of the day.
Ignore him. He had a rough night
and is having an ongoing existential crisis.
Don't worry, you'll get there soon enough.
I married my second husband, Everett, in 1964.
He unfortunately passed in 1976 from a heart attack
while we were vacationing in Kissimmee, Florida.
- It was awful. - Good morning.
We're gonna round, Dr. Mohan.
Excuse me, Estelle. I'll be right back.
So you know we track every resident's
patients seen per hour.
I was just taking her history.
It's a brief backstory about what brought them in,
- not an autobiography. - I was almost done.
You hadn't even made it to this century.
Patients, they check in for registration here.
A nurse eyeballs them, makes sure they're not dying.
If not, they're moved to one of two triage rooms for vitals
and a quick chair exam where you can order
your labs and your X-rays.
And then they come back to…
Waiting room, until a bed opens up.
For how long?
Eight hours, if they're lucky.
A lot of times, 12.
Uh, is it always this busy?
Uh, no.
It gets a lot busier.
Take this.
Hey, Mateo.
Good morning, Cass.
This is Sherry.
Hi.
Sherry, I'm Dr. McKay.
I have some student doctors with me today.
Do you mind if they observe?
- Sure. - OK.
What's going on, Sherry?
I…
I burned my hand on a Sterno.
What were you doing with a Sterno?
Uh, cooking.
You were cooking with a Sterno?
Yeah, we were making s'mores.
That's sweet.
My son loves s'mores.
Uh, we've… we've been here for hours,
and I have to get them to school.
Do you know how much longer this will take?
Uh, yeah, let's see.
- You take anything for the pain? - Uh, not yet.
1,000 of Tylenol,
400 ibuprofen, and saline dressing?
Yes, please.
McKay, we're gonna round.
And the fun begins.
All right, Sherry, we're gonna patch you up
and get you out of here as soon as possible, OK?
- I'll be back. - OK.
As you can see, we have some new faces with us this morning.
Good morning, good morning. Come on over.
Starting with second-year resident Dr. Melissa King,
fresh from the VA.
Everyone calls me Mel.
I'm so happy to be here.
Trinity Santos, intern.
Victoria Javadi, MS3.
Uh, Dennis Whitaker, MS4.
Welcome to the Pitt. I'm…
We've got two traumas from the T.
- Five minutes out. - OK, copy that.
Actually, this is the most important person
that you're gonna meet today. This is Dana.
She's our charge nurse.
She is the ringleader of our circus.
Do what she says when she says it.
As you can see, our house is always packed,
and our department is mostly clogged up with boarders.
Those are admitted patients waiting for a room upstairs,
sometimes for days.
Beds are a very precious commodity around here,
so please be quick and efficient
with your workups.
What else?
We treat the sicker patients back here,
but please keep your eye on that waiting room.
Make sure nobody's gonna die out there.
Your senior residents are Dr. Collins
and Dr. Langdon.
You report to them, and they report to me.
OK? Great.
Senior residents, you got your sign-outs?
- Yep. - Yep.
OK. Let's do this.
Virgil Straker.
9mm GSW to the left shoulder.
CT angiogram negative, surgery wants to admit
for overnight observation.
Good vitals. They repeat a crit?
Stable crits every two hours times three.
Discharge on Ceftin, recheck tomorrow.
He'll get way more rest at home.
Good morning, Mr. Straker. You want to go home?
- Hell yeah. - OK.
Hey. Hey, Ro.
Hey, Ro, I'm finally getting out of here!
All right, Murphy Rottenstein.
48-year-old woman with cirrhosis
and upper GI bleed.
Intubated and stable after one unit.
Awaiting ICU bed.
Hey, Doc.
And we all know Louie Cloverfield.
Blood alcohol of.420 at 11:00 PM.
- I've been cutting back. - How is he still breathing?
That's a lethal dose for you and me.
That's happy hour for Louie.
Sobered up. Had two rounds of lorazepam.
Hold out your hands for me, Louie.
- Another two of lorazepam. - On it.
And a script for Librium.
It's good to see you, Louie.
It's always a pleasure, Doc.
Bar fight with complete avulsion
of tooth number eight.
Smile, Charlie.
Oh! Where's your tooth, Charlie?
Fuck if I know.
Cancel the discharge. Order a chest X-ray.
Got to rule out aspiration.
Incoming!
42-year-old male, Sam Wallace.
Blunt head with agonal respirations.
Dropped down on the T tracks. Couldn't tube him.
- LMA in place. - Suicide attempt?
Rescue. He's a good Samaritan.
Took a spill helping a woman who fell off the track.
- She's right behind us. - OK. Trauma one. Go ahead.
Copy.
Come on.
Woman fell from T platform.
Good vitals and no head injuries.
Degloving injury, right lower leg
with open fracture dislocation to the ankle.
Whoa. OK.
Trauma two. Trauma two. Let's go!
How are we doing? We ready?
OK, here we go. Ready?
One, two, three.
Good breath sounds bilaterally,
but we need to protect…
Apparently he jumped down to save the lady.
When he climbed back up, he slipped,
- fell back, and hit his head. - OK, thanks.
Uh, Mel, right?
I need you on the E-FAST.
Pupils 4 millimeters and reactive.
OK, that's encouraging.
- What do you want for meds? - 120 ketamine, 80 of rock.
- A-fib on a monitor. - Courses clear.
That's a lot more blood than expected.
Um, he's probably anticoagulated for A-fib.
Check his medical records, see if he's on a DOAC.
Stand by with four-factor PCC if there's a brain bleed.
What's in the PCC, Mel?
Uh, clotting factors two, seven, nine, and ten.
OK. Be right back.
50 of fent didn't touch her.
Did she faint or did she trip off the platform?
Nobody knows.
The other guy jumped down, pulled her off the tracks
just as the train was rolling in.
Isolated injury to the foot.
The train ran over her foot?
Got caught between the platform
and the incoming train.
Ma'am? Ma'am, what's your name?
All right, type 3 open fracture.
Two grams Cefazolin, 400 of gent.
Do you speak any English?
Airway and breathing are perfect.
As is circulation.
BP 140 over 85.
Students, what might have made her faint on the platform?
- Uh, TIA, CVA. - Could be an arrhythmia,
- cardiac event. - So she needs…
- Hed CT. - EKG and troponin.
- OK, good. - What do we got, party people?
Subway train degloved her foot
with an open fracture dislocation.
Ooh, and I thought my heels were painful.
- Hemodynamically stable. - E-FAST negative.
Ma'am, I'm Dr. Yolanda Garcia.
Any pain in your chest or belly?
Can we please push the morphine?
No, it could cloud her mental status.
I can't do an exam like this. Push the damn morphine.
We're doing a popliteal block.
Numbs the lower leg, no side effects.
Wonderful. Where's the other guy?
Next door. He's a bit worse.
Pan scan her.
Let me know when she stops screaming.
The cords are very anterior.
Yeah, that's because we can't flex the neck.
Keep the hockey stick straight up.
- I'm in. - Good. Well done.
Bring me up to speed.
Intubated for agonal respirations.
GCS 5. Probably anticoagulated.
With what?
First time here.
There's no medical records.
- Call for FFP? - No, we got four-factor PCC.
80 of mannitol to reduce brain swelling,
then right up to CT.
Do me a favor.
Swap out with Jesse for me, would you?
Of course.
Dr. Robinavitch, do you have a moment?
I'm just a little busy right now, Gloria.
One sec.
Nerve block complete.
Seems like it's starting to work.
Swapping out, Jesse.
Takes ten minutes for the full effect,
and the Marcaine lasts a good four hours.
She's next for CT.
You have any idea what language that is?
Definitely not Tagalog.
Maybe Hindi or Urdu.
I'm gonna go get language services.
Don't you speak, like, five languages?
Six, but that's not one of them.
Six?
And I thought Collins was smart.
Oh, it's way too early
for you to start being an ass, Langdon.
Open hostility in front of the patient?
She doesn't speak English.
Judgmental and dismissive.
How are we doing?
- Vitals stable. - Unlike these two.
Ooh, good for you. Princess made a joke.
Why are you always an asshole?
And I thank you for that beautiful blessing.
- Namaste. - OK, do we have a phone
or anything with a relative's name on it?
EMT said the purse got obliterated
when the subway ran over it.
- Any way I can speak with her? - Highly doubt it.
We don't know what language she speaks.
Hey, um, any chance she jumped?
She may have been pushed.
- Jesus. - Yeah.
Could be looking at a possible hate crime.
I take it you're free now?
We need to talk about your numbers.
- Of people we've saved? - Metrics.
Our door-to-balloon times beat federal standards.
I'm talking about Press Ganey scores.
Patient satisfaction.
If they're still alive, they should be satisfied.
Our goal is 36% very satisfied with their care.
Your department is at 8.
Do you know how likely patients are to recommend this hospital?
This is an emergency department,
not a Taco Bell.
11%.
Well, if you want people to be happier,
don't make 'em wait for 12 hours.
There's a nursing shortage across the country.
Most of our patients are boarders
who are waiting for a bed upstairs.
We don't have the beds.
That's bullshit. The beds are up there.
You just don't want to hire the staff you need
to care for them.
Oh, Doc. Doc, it ain't working.
Man, whatever they're giving me, it's not working.
No response to mag citrate.
Should I send in the Fleet?
OK, sir, we're gonna try an enema.
Like I said, there's a nursing shortage.
Well, if you paid them a living wage,
they'd be lining up to work here.
Our budget can't support that.
Here's a dirty little secret.
The hospital saves money
keeping patients down here in the Pitt.
It's way cheaper than staffing upstairs.
I have asked you repeatedly
to stop referring to the emergency department
as the Pitt…it is derogatory
and incompatible to the institution's image.
You know what's incompatible with the institution's image?
Me speaking to the media
about people who code in our waiting rooms
and people who get shitty care in our hallways
waiting for an ICU bed for days.
I've heard about doctors who have tried that
and find themselves out of work.
Uh-huh.
I know today is difficult for you.
Every day is difficult down here.
Boarding is a nationwide problem.
Your predecessor, Adamson, sure as hell knew that.
Or wasn't that something he taught you?
Fuck. Wow. Really?
Yes, really.
Other hospitals are managing this crisis
much more effectively.
So you can either step up your game,
or you can step aside.
Good Samaritan dude has a small left temporal
intraparenchymal bleed.
No epidural, no subdural, no midline shift in the brain.
Oh, that's good news. He could recover.
CT can take her in five.
Let's have a look. Bandage scissors?
All right.
If an artery is totally transected,
the smooth muscle and the tunica media
contracts with hemostasis.
But if it's a partial cut, get out your umbrella.
Grab a culture from the open fibula before you reduce.
You're up.
I'll stabilize the knee for the reduction.
Dr. Langdon will be distracting distally
before moving medially to clear the tibia.
Good.
Ready?
Med student down.
Good catch on Bar Fight Billy.
There was an aspirated tooth on chest X-ray.
Would have been dead in a week from a lung abscess
had you let him be discharged.
Good call on the pulmonary.
Cardiac arrest, ETA 10 minutes.
- Where should we put it? - Anywhere.
We might have to put somebody in the hall.
Dr. Robby? She, uh, took a fall.
No, I… I tripped on the gurney.
I'm fine.
Why don't you go get a cold drink
in the staff lounge?
I'm fine, really. I swear.
Oh, I know, but it's hospital policy.
Anytime someone gets a paper cut around here,
we have to fill out a workers' comp report.
Other way.
I was fine until about two weeks ago,
after the Rochester Marathon.
OK. Any falls or injuries?
Just tired. Sore muscles.
Yeah, I'd be in bed for a month.
Was this your first triathlon?
God no.
No, I do one every few months.
Have you seen a doctor yet?
Uh, no.
I went for a run this morning.
Had to quit after a minute.
Pretty short of breath.
This goes under your tongue.
- No current meds, no allergies? - Mm-mm.
We're gonna check a few labs and an EKG.
- Draw a red and purple top. - Yep.
Temp 98.2.
Take a deep breath for me, Otis.
Little pinprick now, OK?
Otis?
Otis.
I didn't take him for a lightweight, huh?
Oh, shit. No pulse.
Crash cart! Lay him flat!
- Let's check a rhythm. - Saline pads.
Quick look paddles.
V-tach.
Charging at 200.
Charged.
Clear!
All right, he's back to normal sinus.
Need a gurney in here!
So what's the plan?
ICU when we can get a bed and admit for supportive care.
Repeat head CT in three hours.
Or sooner, if he blows a pupil.
- Want a Keppra load? - Order's already in.
Nice job.
Do you think he'll wake up?
Maybe.
Maybe not.
No good deed goes unpunished.
Oh, has anyone, um, notified the family?
I could try.
Otis Williams. Healthy 31-year-old.
V-tach arrest two weeks after triathlon.
NSR with one shock.
Pulse 98, BP 110 over 60.
He's a little young for an MI.
Exactly right,
What's in the differential, Dr. Collins?
Drug overdose, electrolytes, long QT…
ooh, Brugada syndrome, WPW…
How you doing there, Otis?
OK. What ha…
V-tach again.
200 joules.
Charged, and clear!
Back in sinus.
Otis?
Oh, groaning's good. 5 of nasal O2, CBC,
CMP, troponin, and D-dimer.
What are you doing?
One gram calcium gluconate, IV push.
- We don't have the labs back. - Look at the monitor.
Widened QRS and PT waves.
- Hyperkalemia. - How'd he get that?
Intense exercise caused muscle breakdown.
Rhabdomyolysis knocked out his kidneys.
Now he's not clearing potassium.
I bet it's over 7.5.
Wait two minutes for the I-STAT.
If he arrests again, we might not get him back.
If it's hypercalcemia, you could kill him.
- Wait. - Oh, it's my ass, not yours.
Pan scan is negative.
That means you can admit to orthopedics.
But there may have been a medical etiology
- if she fainted. - That's not surgical.
Get an internal medicine consult,
or admit to medicine with ortho consulting.
Either way, I'm off the case.
OK. Thanks for nothing.
Ancef's in. I'll grab the gent.
Did we figure out what she's speaking?
Last interpreter thought she might be from Pakistan.
There are 77 languages in Pakistan.
OK, well, I will buy lunch for whoever figures it out.
Good luck.
If you need me, I'll be saving lives.
That was wicked.
- That was gross. - Yeah.
Too much for Little Miss Crash and Burn.
- What'd you do with her? - Nothing.
- I think she'll be fine. - Are you kidding?
If that took her out, she'll be lucky to make it
through this rotation.
I got 50 bucks says she doesn't last through this shift.
Come on.
Put your money where your mouth is.
Uh, no. I didn't say anything, OK?
And I sure as hell don't have 50 bucks.
I'll be this lady's age by the time
I pay off my student loans.
Not that you're…
Hey.
You want to sell a kidney?
I could get you 30K as soon as this weekend.
That's just between you and me.
Think about it.
How you doing?
Yeah.
QRS has narrowed.
Much better.
Potassium is 7.7.
Creatinine, 5.6.
High potassium and renal failure.
Just what you thought.
It must be my lucky day.
Ordering 10 units of regular insulin
and 25 grams of glucose.
Why insulin and glucose?
Shift the potassium intracellularly.
Exactly, but the definitive treatment is…
Hemodialysis. I'll call renal
and get a tech down with the machine.
Have you ever seen a dialysis catheter inserted?
Dr. Collins is gonna place a femoral Quinton
under ultrasound guidance.
It's an excellent way to learn.
Oh, my chest.
Yeah, we had to shock you.
You're gonna be sore for a while.
You shocked my heart?
Long story. Dr. Collins will fill you in.
You got a sec?
You OK?
Why wouldn't I be? Are you OK?
Why wouldn't I be?
You seem annoyed with me already,
and I just got here.
It's not always about you, Robby.
Am I gonna be OK?
Yeah.
You just need to take it easy on yourself.
Muscle breakdown and myoglobin damaged your kidneys.
Why'd you shock my heart?
When your kidneys don't work, potassium builds up
and messes with the electrical activity in your heart.
Can it happen again?
We gave you medicine to lower your potassium,
and you'll need dialysis to clear it all out.
Then I'll be OK?
Yeah.
You might need a week or two
for your kidneys to recover, but yeah.
You really need to hydrate like crazy
before and after a triathlon.
Trust me, I won't let this happen again.
Good.
Be kind to yourself, OK?
Oh, hey.
Abbot's told me that he's got a pregnant teen
coming back today for mifepristone.
- Let me know when she gets here. - Yep.
Bowel obstruction, still waiting
on a surgery consult. What about Garcia?
She was just here for the traumas.
I think she was waiting for her attending to sign off.
OK.
Oh, one of the med students took a header.
I parked her in the lounge under the guise
of a work comp report.
Will you just go in there, eyeball her,
and make sure she's all right?
She's gonna miss the morning arrival
of the living dead.
How many are we expecting?
We were getting three, but one died en route.
Don't know who's luckier, us or them.
- What's open? - 14.
89-year-old woman from a SNF.
History of emphysema, CHF, MS.
V-fib, unresponsive to three shocks.
- Two rounds of epi. - What is that?
LUCAS chest compression system.
Robotic CPR.
Everybody get a hold. One, two, three.
Students are dropping like flies.
Take a break. Ice the finger.
You can count on getting a couple elderly patients
every day around 7:30, after the nursing homes
and assisted living facilities do their morning bed checks.
You can practically set your watch.
Was there an advanced directive?
No, full code, per the nursing home.
Seriously?
LUCAS off.
Still V-fib.
LUCAS on.
One more round of epi, one more shock,
and then we call it?
Joseph Spencer, 79.
Fever and cough. From assisted living.
He has a history of mild Alzheimer's.
One, two, three.
Heart rate 130. BP 90 over 60.
Gave him 500 cc's normal saline.
Hi, Mr. Spencer. I'm Dr. King.
This is Dr. Collins.
How are you feeling today?
Is it dinnertime? I…I'm not really hungry.
Do we have any paperwork from the facility?
He has a POLST.
IV fluids and medications are fine,
but no intubation and no chest compressions.
That's helpful.
Coarse rhonchi here.
Right middle lobe infiltrate.
Temp 102. Call a code sepsis.
- Mm-hmm. - Code?
To make sure we check all of our boxes.
The federal government audits our sepsis bundle performance
and publishes the data online.
Today, it better be perfect.
Two sets of blood cultures, lactic acid,
30 cc's per kilo NS, a gram of ceftriaxone,
500 of azithromycin, repeat lactic in three hours.
Nice.
Charging, and…
Stop.
Call it.
Nursing home just faxed us a DNR.
Are you kidding me?
Power off the defibrillator and the LUCAS.
Complete waste of time and money.
Who the hell works at that place?
A nurse taking care of 60 patients
who couldn't find the form.
She called 911 so she could take care of the others.
OK, let's move her to the viewing room
- and notify the family. - Yep.
One of the things we do here is to take a moment of silence
when we lose a patient, to respect their humanity
and also to remember that this was somebody's child
or sibling or parent, friend.
Oh. Ow, ow!
I am so sorry.
Maybe leave it on vibrate while you're working.
- Later, Doc. - You behave yourself now.
Always.
Your med student's back on her feet.
- How old's that kid? - I don't know. I didn't ask.
What is she, some sort of savant?
I don't know. Maybe.
Dr. Robinavitch.
I just wanted to apologize for any trouble
my clumsiness might have caused.
I feel ridiculous.
Oh, I can't tell how many times
I've hit my head on an overhead lamp.
Twice I needed to get staples.
Why don't you go work with Dr. McKay in triage?
That would help both of us.
Oh, I…I don't need special treatment.
Good, because I don't give it.
Look, I know I might look too young,
but I studied my ass off to get here.
Probably harder than the others.
I earned this.
OK, look, I respect your dedication
and your determination, but while you're here,
you're my responsibility.
And when one of my responsibilities
takes a header…wow!
Abbot called for a surgical consult
on the SBO three hours ago.
You're very lucky they didn't perf.
I'm here to see my daughter.
I'm sorry, is that a patient?
You're talking to her.
Am I interrupting?
No.
No, we're done. We're good.
Come find me when you're ready to present your next case.
Thank you.
So how's your first day going?
- It's great. - Yeah?
Yeah, really great.
Hey, Crash, they're doing a dialysis
catheter insertion in North One if you want to check it out.
Mm-hmm.
- That thing… - Did she say Crash?
No.
No, no, it's not crash.
Um, she said crush, 'cause I'm always crushing it.
Um, thanks for coming down, Mom, but I've…
I've got a patient.
Bye.
What do you want?
Um, I…I just wanted to make sure you're comfortable.
I am taking a dump in a dustpan,
so what's that fucking tell you?
Um, I'm…
I'm clearly… I'm clearly in the wrong room.
- Yeah. - I'm sorry.
Mm-hmm.
So it would have been nice if someone had told me
that Eileen Shamsi's daughter was one of our med students.
What, and ruin the surprise?
Was it as awkward as I hoped it would be?
You…you have a mean streak in you, you know that?
What's the deal with the body in 19?
That's Abbot's MVC vet from last night.
Still waiting on next of kin.
- Supposedly on their way. - OK.
Can we move him to the viewing room, at least?
Nursing home DNR is heading there,
joining last night's Jane Doe.
Coroner's office is backed up.
Well, then our morgue needs to take her, then.
Perlah.
Triathlete, Otis?
Oh, he's stable.
Repeat potassium is 6.1.
Renal wrote the dialysis order.
Tech should be down in 15 minutes.
Good. Thank you.
Language mystery solved yet?
No.
Hey, what's your take on dogs?
In what context?
For kids.
Kids and puppies go together like fish and chips.
Man's best friend, you know?
Well, you don't have a dog.
I don't have a best friend.
- What am I? - You're my best resident.
Big difference.
Yeah, but we're still friends.
Not if this conversation goes on much longer.
I have a lethargic four-year-old,
no PMH, no antecedent illness, no fever or vomiting.
Parents just couldn't wake him up this morning.
- What room? - Oh, South 15.
There's no nuchal rigidity,
no skin lesions, no focal neuro.
He looks well fed and cared for.
DKA from new-onset diabetes?
No, BG 85.
CBC, BMP, UA, and UDS ordered.
Can you wake up for me, Tyler?
He's not usually this sleepy?
No, and he barely flinched for the blood test.
He wakes up at 90 miles an hour
and doesn't stop till he passes out at night.
He passes out?
No, he just means he goes all day.
Any chance he could have ingested something?
Any pills, vitamins,
any prescriptions that may have been left around?
No, that's all kept locked in the medicine cabinet.
The whole house is childproof.
Uh, what about alcohol? Anything left out?
- No. - What about pets?
No.
So he's usually, like, quite active?
- Very. - Um, any injuries lately?
No.
Hasn't bumped his head recently?
Not that I'm aware of, but he does love
roughhousing with Drew.
But he never gets hurt.
Oxygen level is normal.
Good pulse and blood pressure. No signs of infection.
We're gonna start with blood and urine tests,
check for any metabolic abnormalities.
It's really throbbing.
Yeah, the blood's under pressure.
Gotta drain it.
No anesthesia, or…
I'll stop before I hit the nail bed.
I hope.
Hey, eyes down here.
Watch and learn.
I'm just looking who to see next.
You're supposed to take them in the order they arrive.
Yeah, I know how it works.
OK. No need to cry about it.
Do you want me to choose for you?
No.
Wow, pain's gone.
- Thank you. - Yeah.
All right.
How about a 20-year-old cough in eight?
Should be easy. Probably viral.
I don't need an easy one.
Suit yourself, Huckleberry.
I'm gonna take the splitting headache.
Maybe I'll catch a subarachnoid hemorrhage or something cool.
Hey, why do you keep calling me that?
Huckleberry?
It's a term of endearment.
It sounds like sarcasm.
You think?
Bordering on harassment.
Where are you from?
Broken Bow, Nebraska.
Jesus, where the hell is that?
It's about three and a half hours west of Omaha.
Oh, yeah, just a little south of nowhere.
What the hell do you do there?
My parents have a farm, so…
You're a farm boy?
Yeah, I guess.
I rest my case, Huckleberry.
I'm so sorry, ma'am.
We don't understand you.
Oh.
Me, I'm Dr. Heather Collins.
I'm from here.
Portland, Oregon.
You.
Where are you from?
Uh-huh.
Uh, China? India?
I can't tell where you're pointing.
Tajikistan?
Nepal.
Mm.
- You're from Nepal. - Nepali.
Mom's got a bad burn.
Needs wound checks and hand therapy.
And I got a sneaking suspicion she may be unhoused.
I'll talk to her. We can offer some help.
Thank you, I appreciate it. Ah, you're back.
Dr. Robby suggested I might be of assistance.
Yeah, I could use the company.
Victoria Javadi, this is Kiara Alfaro.
She's the department social worker,
which pretty much makes her an angel.
- Welcome. - Thanks.
Thank you.
So what rotation is this for you?
Um, third.
I've done OB-GYN and pedes.
You have any favorites?
Not really.
Well, what are you leaning towards?
I'm not really sure yet.
OK, well, you have time.
Uh, can I actually ask you a personal question?
I'm 20, and I've earned the right to be here.
Oh.
Yeah, I don't…I don't doubt that for a minute.
I…I was actually wondering if Dr. Eileen Shamsi from surgery
is a friend or relative of yours.
I saw you talking to her in the hall and I thought…
Yeah, she's my mother.
Oh.
Oh, wow.
Oh, that's cool.
- You're really only 20? - Yeah.
And for the record, my… my father also works here.
He's an endocrinologist.
Oh, so it's like a family business.
I'm sorry. That was a joke. That was a joke.
And I'm sure that comes with a lot of pressure.
And as for the age thing, I'm a 42-year-old R2,
so I have my own haters, trust me.
OK.
Um, sometimes when it gets busy,
we'll help the nurses bring back patients.
- OK. - Um, OK.
Next to come back is Fred Saeta.
- Knee pain after a fall. - Great.
- Fred Sa… - Doc. Hey, Doc. Hi.
Hi. Doug Driscoll.
Any chance someone could see me now?
I've been here for, like, two hours.
Unfortunately, Mr. Driscoll, there's a lot of patients
still ahead of you, some of whom are severely ill.
Yeah, and I got chest pains that woke me up
- in the middle of the night. - Chest pain.
- Yeah. - No, it's not plural.
It's just chest pain, not chest pains.
Yeah, and if I have more than one, it's chest pains.
- Are you even a real doctor? - She's a student doctor.
Yeah, well, keep her the hell away from me.
I just need to see someone, OK? Not her.
Isn't chest pain an emergency? I don't…
It looks here like you got an EKG
five minutes after arrival, so it's not a heart attack.
Yeah, but I'm supposed to get a chest X-ray and blood tests.
Ah, and you are next in line for lab tech, OK?
So listen for your name. Excuse me.
Fred…
Actually, can you get me a wheelchair, please?
Uh, hi. I'm…I'm Dr. McKay.
What's going on?
I, uh, found her on the floor in the bathroom.
- She can't stop puking. - What's her name?
Theresa. She's my mom.
Theresa?
Theresa, are you taking any medication?
No.
Any previous stomach problems?
No.
When did the vomiting begin?
Um, last night.
- Last night. - Oh, come on!
Do you have any dizziness or fatigue?
Mystery solved.
Our lady with the degloved foot is Nepali.
Oh, hey, congratulations.
Otis's BP is crashing. 70 over 50.
Still waiting for dialysis.
How you doing there, Otis?
- Not so good. - 50 liters.
Non-rebreather, please.
Oh, crap.
Diastolic collapse of the right atrium and right ventricle.
Tamponade from uremic effusion.
- That's why his BP is low? - Yep.
Too much fluid and pressure
around the heart, chambers can't fill.
Otis, you've got some fluid around your heart.
We need to get it off.
What's happening?
25 of Propofol, 10 cc's of lidocaine with epi,
pericardiocentesis tray.
I have to get that from central.
No, no. Just open a central line kit.
Dr. Santos, take the head of the bed
and bag him if he stops breathing,
compressions if we lose the carotid.
Prep and drape the subxiphoid, please.
- 10 cc's of 1% with. - Chlorhexidine here.
- 25 or 27-gauge? - Long 25, 25.
Thank you.
Injecting lidocaine.
Pressure down. 60 over 40.
Right.
Wait, you can't ultrasound and place.
I know, that's why I'm taking the probe.
18-gauge thin wall
on a 60 cc syringe, please, Dr. Collins.
Let's go.
You're going in right over the center of my probe,
advancing very slowly.
We're looking for the hyperechoic tip.
Very, very slowly. Do not hit that heart.
Dr. Santos, do you see that sea of black?
That's the effusion.
We're looking for a little white dot.
There it is.
Got it.
Aspirating.
3 cc's should be enough.
Good.
Next, we'll place the guide wire,
and then the triple lumen catheter.
Pulse ox is 99.
Pressure is up. 124 over 78.
Looks like things are back to normal.
That was cool.
Four Zofrans on board.
That should stop the nausea.
David, have you had any vomiting?
- No. - Anyone else sick at home?
No, it's just us.
My husband passed away a few years ago, from COVID.
Oh, I'm so sorry.
Potassium, 3.1.
Is that bad?
It can cause heart problems.
But we're gonna correct it, OK?
10 in the bag, 20 PO.
Javadi, any questions?
Um…
uh, David, have you two traveled
out of the country recently?
We never go anywhere.
Is she gonna have to stay here?
If the rest of the tests are good,
and she responds to treatment, she can go home.
Mr. Milton, my name is Dennis Whitaker.
I'm one of the student doctors here.
I'll be seeing you first.
Nice to meet you.
BP's 150 over 90.
That's just a touch high.
I forgot to take my damn enalapril this morning.
Oh, we'll get that for you.
Tell me about this belly pain.
Uh, it started about here.
Um, woke me up at, like, 2:00 AM.
Pretty intense.
Lasted about an hour.
Now it's gone.
Any fever or vomiting?
Nah, I never get sick.
OK.
Uh, what did you eat last night?
Oh, it was my wife's birthday.
I took her out to Sullivan's for a steak.
Oh.
Well, the exam is pretty benign.
I'm gonna test for gallstones.
If there is a stone and you eat fatty food,
there can be pain when the gallbladder contracts.
Oh.
Uh, bingo.
One stone. There it is.
Do I need surgery?
Uh, you should be able to manage with a low-fat diet.
But we'll send off labs for liver and pancreas.
Just let us know if you have any more pain.
OK.
Thanks.
Yeah, you bet.
Great.
You want an EKG?
For?
Heart attacks can present as upper abdominal pain.
Um, yeah.
No, yeah, that's a great idea.
Thank you.
I'm going as fast as I can.
I'm picking up two more patients.
I didn't say anything.
I, uh…I need a fresh set of eyes.
On what?
54-year-old woman brought in with intractable vomiting
by her 18-year-old son.
I'm, um… I'm getting a weird vibe.
How so?
Like, I don't know, maybe she was given something.
Some sort of elder abuse.
There's just a strange dynamic I can't quite figure out.
You're really good at sussing out that sort of thing.
I don't know about that.
Uh, excuse me, Dr. Langdon.
Almost all of our labs are back on sleeping boy Tyler.
All 100% normal.
What are we missing?
Is he waking up?
No, he's… he's still fast asleep.
Most of the lab results are in, and they look great.
No abnormal blood count, no, uh,
electrolyte abnormalities, no diabetes,
no, um, kidney disease, so…
Good. So…so what's wrong with him?
We're still trying to figure that out.
Did he, uh, have a playdate yesterday, by chance?
No, he had preschool,
but he was fine when I picked him up.
Any kids in his class ill?
No, my phone tree would have lit up
if someone else was sick.
He eat anything this morning?
No.
Why?
It looks like some sort of gelatin.
Any chance he could have gotten
into some bath beads or laundry pods?
No, there's no such thing in our house.
What about gummies?
No, we're very strict about candy.
Right?
Oh, shit.
Danny.
What about Danny?
Your brother, he…
he gave me some gummies he got in Cleveland.
They were in my coat pocket.
Are you fucking serious?
Pot gummies?
Yes. I'm so sorry.
Let me call the lab. Maybe the tox screen is back.
Hey, this is Dr. Langdon from the ED.
Can I fast-track a lab on a little boy,
last name Jones, first name Tyler, tox screen?
Get the fuck out! I mean it.
Why don't we step outside, and maybe you can help me
figure out how much he may have taken.
Thanks.
I appreciate that quick turnaround.
The labs confirm it.
Your son tested positive for cannabis.
This is a fucking nightmare.
Theresa, David, this is my attending, Dr. Robinavitch.
Hi, I'm Dr. Robby.
We need to do a pelvic exam.
And David, I don't think you want to be in here for that.
Definitely not.
Can you have Nurse Perlah come join me, please?
Do you want a coffee or a soda or something?
Why do I need a pelvic exam?
Uh, you don't.
Your son seems like a nice kid.
He's clearly worried about you.
But your exam and your labs are not matching
any of the usual diagnoses,
so I'm not really sure what's going on.
I'm not here for me.
- I'm here for David. - I don't understand.
He said that you've had persistent vomiting,
some…some dehydration.
I made myself sick with ipecac.
To induce vomiting? Why would you do that?
So David would bring me here.
My son has some problems.
He needs professional help.
OK. What kind of problems?
Drugs, alcohol?
I found some of his writing.
I thought it was schoolwork, but it wasn't.
It was lists of girls he wanted to hurt.
Hurt them how?
He said, "They should all be eliminated."
Has David seen a therapist?
No.
He's not a bad kid, but I'm afraid he's troubled,
and I didn't want to call the police
because I was afraid they'd overreact.
- He's just a kid. - How old is David?
He just turned 18 last month.
Then he's considered an adult
and he would have to consent to treatment.
Do you have any guns in the house?
No.
My husband did,
but I got rid of all of them after he passed.
He's a good soul.
I just don't want to see him hurt anyone or himself.
How are you feeling, Crash?
I'd really appreciate if you didn't call me that.
Why not? It's a cool nickname.
You earned it. You should own it.
I don't like it.
All right. It's just a joke.
You know, if it makes you feel any better,
I sharted the first time I saw an emergency C-section.
Really?
Of course not.
Excuse me. I'll be right back.
I got a situation.
18-year-old kid brings in his dehydrated mom.
Dad died during the pandemic.
Mom's vomiting is self-induced for the sole purpose
of getting him here after she finds
his death list for classmates.
I…OK.
What does she want us to do?
Help him, protect him, save him.
- Where is he now? - Talking to McKay.
How are you doing?
Me? I'm good.
I'm always good. You know that.
Do I? Does anybody?
- I'm an open book. - Not even close.
You do know you can always come talk to me, right?
Yep.
- How's it going over here? - Good, good.
We're just going over aftercare instructions,
prescription medications, special diet
for the next few days.
Dr. McKay, can you check orthostatics on Mom?
I can.
David, I wanted you to meet Kiara.
She's a social worker here who helps
in situations like this.
We heard about your father's passing.
We're really sorry.
And we know that it can put a lot of pressure
on somebody your age, which, combined with school
and now having to take care of your mom, that's a lot.
It's fine.
We just want to make sure that when your mom goes home,
you can handle it.
We want to make sure you have someone
you can talk to if you need to.
I'm OK.
I don't need to talk to anybody.
After a parent dies,
the sadness can last a long time.
How's that going for you?
It's not a problem.
What about school?
What about it?
Anything you enjoy there?
Not really.
A lot of people have thoughts that can disturb them.
If you've had any, it's OK to talk about it.
What's that have to do with my mom?
- Is she gonna be OK? - Yeah, she's gonna be fine.
She's probably got a stomach virus,
maybe food poisoning.
I think she's more worried about you.
She always worries about me.
- Does she have a reason to? - No.
It's almost 8:00. I gotta go.
Are you sure you wouldn't prefer to wait with your mom?
I'm late for school.
She can just call me when she's ready.
It would actually be kind of helpful
to talk to you some more.
Hey, David.
David.
Just give me five minutes.
Leave me alone!
Hey, David!
Shit.
Robby!
Robby.
Got a college kid, respiratory arrest,
coming in hot.
Robby, we need to intubate here.
Dr. Adamson just went down with a pulse ox of 65.
Robby!