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- Robby. - Yep.
Cellulitis on the dorsum of the foot,
now spreading up the leg.
Hello, I'm Dr. Robby.
Mind if I take a look?
How long do you think this is gonna take?
I took an early lunch break.
I don't know that you're gonna
make it back to work today.
Erythema and warmth halfway up her knee.
When did you see her, Donnie?
He didn't. I did.
- When? - About four hours ago.
Gave her a dose of Keflex,
told her to come back if things got worse.
Things have definitely gotten worse.
Dana, what's open?
Trauma Two.
Jesse, can you get her started in Trauma Two
with some vanco and blood cultures, please?
- Got it, boss. - I'm coming with.
Suit yourself.
Santos, you want in on Trauma Two?
Too much charting, too little time.
62-year-old male presents with chief complaint
of left lower back pain.
- Considered the diagnosis... - Hey.
Oh, Jesus Christ.
I'm charting.
Sorry.
Did I do something wrong?
Besides interrupting me? Probably.
Then I apologize.
I know that second year of residency can be stressful,
so if there's anything I can do to help you...
like stop talking.
- That's a great idea. - Yeah.
Considered the diagnosis of aortic aneurysm or dissection.
Got a new one for you in 13.
I'm 20 charts behind, and the new attending
is threatening to make me repeat
a year if I can't catch up.
Cry me a river.
Old lady with bad abdominal pain.
Somebody's gotta see her.
Dana, please do me a solid.
Holiday weekend.
Westbridge is down, and our waiting room's on overdrive.
I'm sorry, but your charting's gonna have to wait
until after your shift.
Ogilvie.
Dr. Santos needs you to pick up a new patient in 13.
Y-yes, ma'am. I'm on it.
Chart while you supervise.
Best I can do.
Setting up a GoFundMe, that's what her generation does.
That's how they support each other.
Doctor, tell him.
Your wife's right.
Staying here's gonna cost more than we can afford.
Look, I'm feeling better.
I'll just leave.
Mr. Diaz, even if your blood sugar is back to normal,
we have to continue with the insulin drip
until we clear the ketones from your bloodstream.
Otherwise, you could experience electrolyte disorders,
heart and kidney problems...
Mi amor, your health is what matters.
I'll make you a deal.
You agree to stay on the insulin drip,
and I'll go find our case manager
to discuss cost-cutting options for your stay.
Deal.
And I'm sitting here making sure he doesn't move.
- You should go look for Ana. - Mm-hmm.
I can find her.
BRB.
Hanging vanco.
What's vanco?
A really strong antibiotic to kill skin germs.
- Need a hand? - No. We got this.
I'll just observe.
Pretend I'm not even here.
Let's send off a CBC, blood cultures, and CMP.
And also a lactic acid, CRP, and calcitonin.
Wait, she's not febrile, not tachycardic.
No evidence of SIRS.
- Yet. - What's SIRS?
Systemic inflammatory response syndrome.
Sorry.
An exaggerated defense response.
A what?
Sometimes the human body can have an overreaction
to an infection, so we're gonna monitor you
to make sure that this does not progress.
It's my boss.
Sorry, I have to take this, or he's gonna fire me.
OK.
Hello.
No, I'm still at the hospital.
Being seen right now.
Ow.
No, they just stuck me with a needle.
I don't know.
You wanna talk to them?
They're kind of busy right now.
I know you are.
Second IV's in.
No, I'm not overreacting.
My body's overreacting.
Please... please don't fire me.
I...
This is Dr. Michael Robinavitch.
I am the chief of emergency medicine at PTMC.
If you fire her, she will sue you,
and I will testify on her behalf.
OK.
Don't worry about it. We got you.
Do you know how long Jackson's gonna be asleep?
So there's no exact timeline with the sedatives we gave him,
but he should be awake soon.
Have you spoken to your parents yet?
Yeah, they're on their way back from Columbus.
Maybe you should take some time for yourself
before they arrive.
Yeah, cafeteria's right down the hall.
Decent grilled cheese.
Stay away from the tuna.
Thanks, but I'm not hungry.
You know, I just can't believe that a campus security guard
tased my brother.
Aren't they supposed to be helping students
and protect them, not shoot at them?
You have every right to be upset,
and you should absolutely pursue accountability.
But right now, we are taking care of your brother.
And you should really take care of yourself.
I... I have your number.
I'll text you as soon as Jackson's LP results get back
or if he wakes up.
OK.
OK, thank you.
Of course.
- Oh. - OK.
Hypoactive bowel sounds.
Soft, with moderate tenderness in the left lower quadrant.
Mrs. Randolph, do you take Percocet every day?
- No. - Huh.
And what about your water intake, 'cause...
Pause.
Mrs. Randolph, you said you don't take Percocet every day,
but when was the last time you took some?
Maybe three or four times last week.
Assisted living had a ballroom dance competition,
- and I tweaked my back. - Mm.
Any further questions, Ogilvie?
When was your last bowel movement?
I don't know. Sometime last week.
I've been stopped up for at least five or six days.
Mm-hmm, painkillers can cause constipation.
I know.
That's why they put me on a stool softener,
and then they tried an enema.
- And... and no movements? - Yep.
And then they gave me this horrible drink.
Mag citrate.
Yeah.
Mag citrate.
Made me puke.
All right, what's next, Ogilvie?
Let's get you an X-ray and see how we can help you,
Mrs. Randolph.
- Thank you. - Yeah.
Differential?
Probable stool impaction.
But with her history of cholecystectomy,
it could be small bowel obstruction.
Or worse.
Sigmoid volvulus?
But that's a surgical emergency.
Wouldn't she have tons of pain?
Not always, especially when you're in your 80s.
I am getting concerned.
This is a millimeter past the line.
Or my line was sloppy.
- Any increase in pain? - Oh.
OK, sorry. Let's try four morphine.
White count's only 10,000.
It'd be over 12,000 for SIRS.
There are other criteria.
Still afebrile.
Did you ask about past history of MRSA?
Not specifically, but she's never been hospitalized.
Any evidence of an immunocompromised state?
- No, she's healthy. - Steroid use?
Never.
Maximum heart rate's only 89.
Is that OK?
That's good, very good.
Stay with her.
Monitor her closely.
If there's any change in her condition, come find me.
I mean any change.
Roxie Hamler, 42, home hospice patient
with a history of lung cancer.
New-onset tonic-clonic seizure with right lower leg pain.
She hit it on the coffee table.
Initially nonverbal, now coming around.
That's normal after a seizure.
- Hi, I'm Dr. Al-Hashimi. - Do you need a hand?
- Nope, we got it. - She hit her head?
No. I was there.
- I caught her. - No IV?
Couldn't get one in.
Gave her four of IM versed for the seizure,
- 25 of fent for the pain. - OK.
- Dana, where to? - Trauma One.
This way.
Haven't seen you guys in a hot minute.
Pickup from SCI Jones Forge.
Was supposed to go to Westbridge but got
diverted to you.
Yeah, you and everybody else.
Princess, I need you pivot to Central 9.
Got it.
Gus Varney, 54, victim of assault
with diffuse blunt trauma.
He's got bruising to the face, the right chest,
10-centimeter laceration to the left arm.
BP's 136 over 84, pulse 102,
good sats, 95 on room air.
How you feeling there, Mr. Varney?
- Fucking hurts. - Where?
- Everywhere. - I am Dr. Robby.
This is Dr. Al-Hashimi.
We'll get you something for the pain.
I've got a progressing cellulitis in Trauma Two.
- Go. I'm good. - Thank you.
Gus, do you know who hurt you?
One of the fine, upstanding citizens of cell block 6.
It's a deep lac through the muscle fascia.
Can we get the cuffs off once he settles?
Not a chance.
Orange jumpsuit. He's cuffed for a reason.
Let's go.
OK, everyone, on my count.
1, 2...
Hold on.
- Go. - 1, 2, 3.
Mel, E-FAST.
Whitaker, primary assessment.
On it.
Oh, weird bruise.
Did he fall on something?
Footprint, got stomped.
Jesus.
Is it... is that necessary?
Afraid so.
Airway's patent.
Good lung sliding on the left.
Sorry.
Good on the right, too.
How are the lungs?
Good breath sounds.
- No crepitus. - No effusion.
Pulse ox 97, BP 118 over 78, heart rate 112.
Tachycardic from the pain.
Start with four of morphine. Repeat prn.
On it.
OK. Swollen mandible.
Open your mouth for me, Gus.
Little wider.
Can't.
Whitaker, you know the tongue blade exam?
Yeah.
It's a great test for mandible fracture.
Gus, bite down hard on this for me.
Sorry, Gus.
Positive test.
No free fluid in the belly.
Any idea how long this will take?
Too soon to tell.
Whitaker, your assessment?
Fractured left mandible,
multiple rib fractures.
Complex forearm lac.
OK, log roll to the left, then pan scan.
Where were you when Mr. Varney got assaulted?
I just move 'em. I don't get to know 'em.
CT's ready for us.
Cycling the BP.
OK, this redness is now a centimeter over that line,
and this might be a bulla forming.
The vanco takes a little time to work.
Vital signs are still stable, 122 over 78.
I got it.
How are you feeling, Debbie?
I'm feeling a little warm.
That can happen with vanco.
Thanks, man.
Lactic acid 4.2.
- OK. - What's wrong?
That can be a sign of a more serious infection,
but the good news is, we know what to do.
Jesse, 2 liters of LR wide open.
This is severe sepsis.
I know, but at 7:00 AM, it was a simple cellulitis.
Anyone would have given her Keflex.
We could add carbapenem or Zosyn to broaden
our antibiotic coverage.
OK, I got it.
Thanks.
Jesse, 1 gram meropenem, 900 milligrams clinda,
and page Dr. Garcia, please.
What's going on?
We're adding new antibiotics.
It's serious?
We wanna get ahead of it and make sure
it doesn't become serious.
What else can I do?
I think you've done enough.
You can go.
All good in there?
Code sepsis.
Stable for the moment.
How about you?
Perfect vitals, E-FAST negative, off to CT.
Good.
Keep me posted.
Ditto.
How's it going?
Great, if you ignore the hot mess in chairs.
Any update on our little baby Jane Doe?
Security's reviewing the CCTV from last night
and this morning.
You two kiss and make up yet?
I think someone needs to smoke a cigarette.
I'm trying to quit.
Why don't you quit when I'm on my trip?
Everyone's glad to have you back.
- Asshole. - Well, not everyone.
Hey, you want in on this betting board?
Look, all you gotta do is pick why Westbridge went down,
how many of their patients we're gonna get,
and when they'll be back in action.
Hey, already up to $500.
Oh, ah, gotta pass.
Still catching up on rehab bills.
Respect.
All right.
What's the rules on me changing my bet?
Only if you double down.
Sinkhole.
You watch too many movies, man.
Considered the diagnosis of aortic aneurysm
or dissection, but the point-of-care ultrasound was...
You done want that gridlocked granny?
Ordered an acute abdominal series
to rule out obstruction.
- Still waiting on the X-rays. - Great.
Then you're free to treat our latest
and greatest in South 16.
Oh, come on, D, it's like, every time
I get a moment to chart, I barely get
- a sentence out before I get... - Interrupted?
Sucks to be you, but trust me, it sucks worse
for the poor gal in 16.
I'm beginning to think you enjoy torturing me.
Perks of the job.
Ogilvie, let's go.
Hold out your hand, Louie.
A little shaky.
No surprise.
I've been here since 4:00 AM.
We can get you something for that.
Or I can take care of it myself
if you cut me loose right now.
Let's get Louie 50 milligrams of Librium.
I'll put in the order.
I will get it from the PDS.
I'm already assigned as Louie's treating physician.
Just makes sense that I put it in.
Yeah. Yeah, yeah. Of course.
Any changes with our septic waitress?
Not yet.
Wait, if you have a second, I...
I don't.
But the point-of-care ultrasound
was negative for both.
I considered the diagnosis of cauda equina syndrome.
You writing the great American novel?
Charting and supervising.
It's Dana's idea.
Who's the lucky patient?
Unhoused woman with a bad cough.
Ogilvie's all over it.
OK.
Say "eee."
Eee.
OK, deep breath in.
Blow it out real hard.
You haven't heard enough already?
I need to check for wheezing with forced exhalation.
Fucking cough is killing me.
You smoke, Mrs. Yardley?
Yeah, but I haven't been able to
for a couple days 'cause of this cough.
Mm. You ever consider quitting?
You ever considered minding your own business?
Well, the good news is that your test from earlier
came back negative for both COVID and influenza,
but I'm gonna order a chest X-ray
so that we can see what's really going on in those lungs.
You got time to let us do that?
Where the fuck else you think I gotta be?
And we're in.
3 grams Keppra over 10 minutes.
That'll prevent another seizure.
Thank you.
Nobody can ever get an IV in her.
Yeah, midline cath is the way to go
when your veins are shot.
Tachy to 114, BP 94 over 70, sat 91 on 2 liters.
- OK. - Cold.
Is it possible to get her a blanket and some socks?
Can do.
When was she diagnosed?
Seven years ago.
Resected a lobe.
Four cycles of platinum chemo gave us a couple good years,
but then it spread to the bones.
Has she had radiation therapy?
Shrunk down the mets, but they're still there.
That's why you're at hospice at home.
Yep.
I'm sorry.
Me too.
Ah.
Sorry.
You have kids?
Yeah, two boys.
15 and 9.
My son's 12.
Goes fast.
Too fast.
Swelling and bruising over the distal tibia.
50 of fentanyl once her systolic's over 100.
What do you usually take for pain?
MS Contin, 30 milligrams twice a day,
oxycodone for breakthrough, and sublingual Actiq
for when it gets really bad.
That's a lot.
You handle her pain meds?
Sometimes.
All the time.
A hospice nurse comes by a few times a week,
but I was alone when she had the seizure.
They told us that it could happen,
but she couldn't breathe.
And I freaked out, and I called 911.
I'm so sorry.
I'm sorry.
Due to your family income, you make too much
to be eligible for either PENNIE
or the hospital's "charity care."
But we can't afford health-care premiums.
It's unfortunately very common for people
to fall between the cracks.
It's an imperfect system.
Can PTMC help with the costs in any way?
We can offer financial assistance.
You'd pay the same that Medicare
and Medicaid would pay.
How much is that?
You pay 60%, we cover 40%.
Thank you.
Uh-huh.
Where have you been?
- How are you doing? - I'm sorry, mijita.
You were being thoughtful, and I just blew up.
Well, Ms. Noelle was just telling us that the hospital
is gonna give us a big discount.
We can knock 40% off your final bill.
- That's great. - Mm-hmm.
I stay here for a few days,
my bill could be over $100,000, right?
Yes, unfortunately.
It could end up being lower,
depending on your level of needed care.
Or higher?
So we would still have to pay $60,000?
Which we don't have.
He has to stay here to get better, right?
- Yes. - No.
Excuse me?
I mean, not necessarily.
Couldn't we just admit him to med-surg instead of ICU?
Wouldn't that be a lot cheaper?
Med-surg won't accept him with an insulin drip.
Usually true.
But let me talk to the charge nurse upstairs, and I'll...
I'll see what she says.
Thank you.
Food poisoning in the hall's asking to leave,
wants to take her kids to the water park.
Those places are cesspools.
Preaching to the choir.
If she's feeling fine on Zofran, she's good to go.
All right.
Louie's in South 15. Meds are coming down.
Another couple hours of monitoring, and he can broom.
Straight to the liquor store.
Don't pass "go."
What about that clamshell case
that went up... anything?
Out of surgery, in recovery, still sedated.
Good. Keep me posted on that.
Will do.
Three times in one day.
To what do we owe the pleasure?
I came down for a consult
and to persuade Ahmad to start a new betting board.
Why, is the Westbridge board full already?
Mm-hmm, was gonna ask him to start one about you
and your midlife crisis trip.
I give it four weeks.
Seven, tops.
Ye of little faith.
Not about faith, just facts.
Facts?
Based on my experience, you're a seven-week-itch
kind of guy.
Hey, Robby, med student's got a pickleball player
in the North Hall with possible Achilles rupture,
asking for your opinion.
Thank you, Perlah.
At least somebody down here has a little faith in me.
You know what Motorcycle Mike's sabbatical is really about?
I never try to guess what's going on in that head of his.
Three months being on the open road by himself.
Man can't stand to be alone for more than a few hours.
He sleeps with the TV on in his bedroom.
I really don't think I needed to know that.
Look, maybe he's looking for something new
or trying to outrun some old ghosts.
Well, I hope he finds what he's looking for.
Man deserves some peace.
Amen.
I considered the diagnosis of cauda equina syndrome,
but the motor and sensory exam
were both intact in the sacral nerve root...
Our unhoused cougher has pneumonia.
I'm cursed, fucking cursed.
Fuck.
What?
That is a cavitary lesion in the right upper lobe.
Active TB.
What's next?
AFB stain to confirm,
move her to a negative airflow room, start her on meds.
Call infection control and public health.
And now you get to sign in as a patient
and get your blood drawn for a QuantiFERON Gold.
It's too soon to be positive.
Yeah, but you were exposed.
You need a baseline test
and then again in eight weeks to see if you convert.
And if I do?
Then meds every day for three or four months
with regular blood tests to check for toxicity.
- Jesus. - All right.
Let Dana know what's up.
And for the love of God, mask up when you move her.
- Dr. Langdon. - Hey, man. Alex.
Let's take a look.
Ah.
Is it bad?
It's not good.
Sorry, your chart says you were burned with dry ice?
- What happened? - My jack-off brother.
Does he not like you?
I asked him to do it, just not like this exactly.
What? Why?
He was gonna brand me like I branded him.
Branded? Like cattle?
Instead of hot branding, you stick the iron in dry ice,
let it get super cold, and then you put it on your skin.
Cool, huh?
Let's get some LET on this.
I'll get some snips to debride.
You good?
Yeah. Yeah, good.
You sure?
Doesn't seem like Robby's all that happy I'm back.
Well, he's not going to be here,
and I'm happy you're back.
Thanks.
Head and neck CT is negative, except for mandible fracture.
OK, let's get him off the board.
Roll him, right side up.
Hey, we're gonna need the cuffs off.
Ready. And 1, 2, 3.
Ah, gentle.
Dr. King, how are the chest and belly?
We have three anterior rib fractures
and a small pulmonary contusion.
- Not too bad. - Mm-mm.
When do pulmonary contusions peak?
After a few hours.
And do we always admit for three-rib fractures?
In the elderly, yes,
but not if a patient can manage the pain
and doesn't need supplemental oxygen.
OK, he's really hurting here.
You think you could set us up with a serratus anterior
- field block? - No problem.
Oh, as long as that's OK
with Dr. Al-Hashimi.
If the patient consents.
Mr. Varney, we wanna give you a shot to numb your broken ribs
so you can breathe easier.
Uh-huh.
OK, get Mr. Varney prepped and draped.
Dr. Mohan, you're in charge.
Let's identify the landmarks.
Cuffs.
Yeah, you can just leave them off, man.
He's clearly not moving on his own.
We follow protocol,
for his safety and yours.
Do you need to get that?
Nope. It's my mom.
Ignore it. Just ignore it.
- Amen, sister. - Forearm is numb.
We can irrigate.
If I ignore a problem for long enough,
it just goes away, right?
I wish I could ignore my deposition.
That, you can't ignore.
But you'll be fine.
What's up with you, Whitaker?
Trouble in roomie land?
No, not really.
I think I overstepped with Dr. Langdon earlier.
Oh.
He was trying to prescribe a patient benzos,
and I told Langdon that it'd be better if I did it.
Oof.
Only because I was already the assigned physician.
But yeah, now I feel like an asshole.
Langdon's fine.
He went to rehab, he's working the steps,
and hopefully it's all behind him.
Place the needle in-plane,
superficial to the serratus anterior,
between it and the latissimus dorsi.
Mm-hmm.
You can see the fluid dissect and diffuse...
Dr. Mohan, we need you.
We've got two more rigs from Westbridge
pulling up right now.
Go. We got this.
Thanks.
How we doing in here?
Spiked a temp to 102, gave Tylenol.
Check out her leg.
That is a definite bulla.
Did surgery come down yet?
- Not yet. - I need surgery?
Page them again.
Surgery would be a last resort.
We would like them to come down and check out your leg
in case we need to remove this infected skin.
I thought it was just a little swelling
'cause I'm on my feet all day.
BP's down to 85 over 40.
- How much LR is in? - Full bolus.
Do another liter and then start Levophed.
Titrate to a MAP of 65.
Can someone please tell me what's going on?
Pulse ox down to 89.
100% non-rebreather.
Sometimes an infection can cause your blood pressure
to drop and lower the amount of oxygen in your blood.
Am I gonna be OK?
We're doing everything that we can
to make sure that you are.
Jesse.
What's up?
Be ready to intubate if you need to.
- You want me to call Langdon? - No.
I will be right back, and you can call surgery
and tell them to get their heads out of their asses
and get down here.
Did you bring Langdon back here?
No, Al-Hashimi did.
You banished him to scut purgatory.
He did everything you would've done
with that cellulitis patient.
If you think he missed something, tell him.
Well, we're probably gonna need to intubate.
We're definitely gonna need an ICU bed.
What happened?
She is in septic shock, on pressors.
Open shoulder dislocation is back.
Westbridge shut down all their ORs, so they told us
- to bring them back here. - You joking?
This ain't the Radisson.
Not my problem.
- Where should we park him? - Grab a wall.
Call Noelle. Call ortho.
Call the OR and tell them we got a patient back
that needs surgery and admission.
Hey, so sorry about this ambulance tour
of Allegheny County, Mr. Billings,
but we got you from here, I promise.
Yeah, I'm starving.
Is there any way I can get something to eat?
Sorry, not before surgery.
Can I have a visitor?
Sure.
Any word from Gloria about what's going on at Westbridge?
Radio silence from the ivory tower.
And the charge nurse over there isn't responding.
Must be bad.
I wonder if it's something that security needs to know about.
I'll keep you posted.
Hey, you're kind of buds with Gloria.
Did she say anything to you about what's
- happening at Westbridge? - No. You?
Nope. How are your patients?
Our prisoner, Gus, has stable injuries,
and our law student in Central 10 is awake,
normal LP, and awaiting a psych consult.
Good.
Quicker we can treat 'em, street 'em, move 'em
up the food chain, the better.
Question.
Why are you treating me like one of your residents?
I'm not.
As the attending, I like to know the status
of all the patients and doctors in the ED
in case I need to jump in quickly.
Makes sense.
Now your turn.
What?
As your fellow attending in our ED,
it only makes sense for me to know the status
of all the patients and all the doctors
in case I need to jump in on a moment's notice.
Touché.
You have a non-displaced fracture, distal tibia.
So if you look at the bone here, it's pretty well aligned.
Sorry. Hi.
Hi, I was in the shower, and I came as soon
as I got Paul's message.
- Lena? - Hi.
What happened?
I had a seizure.
You load her with Keppra?
Yeah.
Yeah, she's back to baseline mental status.
I'm sorry, I'm confused. Aren't you off duty?
- I'm Roxie's death doula. - Oh.
Her... her what?
I help advocate for people like Roxie
to make their transition to death a more peaceful process.
It's like a birth doula but for the end of life.
She's been a real lifesaver for our family.
My husband cracking jokes while I'm dying.
See why I married him?
Whatever you have to say about my condition,
you can share with Lena too.
We were just explaining that Roxie
has a pathological fracture through a metastatic lesion.
Can you fix that?
The bones are well aligned, so she won't need surgery.
The treatment is immobilization
and a long leg boot.
Oh!
Maybe we up her pain meds.
Yeah, sure.
We can do that.
The bones should heal in about six weeks.
If I live that long.
Still numb here?
Yeah, bro.
Great.
You think it's gonna leave a scar?
I don't think it. I know it.
Holy shit.
Fuck are you doing here?
I'm sorry, who are you?
Concerned brother.
That looks not too bad.
You gooning me?
Yeah, it's nasty.
Thanks to you.
You did this?
Oh, yeah. You wanna see the video?
- Yes. - Definitely.
Got you.
All right. All right, get in close.
Brothers unite!
- Ooh! - Ooh!
Dude, why in the world
would you ask to have that done to you?
He was trying to brand me with our family crest.
Your family crest is the Penguins logo?
We were gonna be bonded for life.
You already are, with DNA.
Yeah.
I love you, man.
- I'm real sorry. - It's OK.
Doc said it's gonna take some time, but it'll heal OK.
Awesome.
So maybe we can try again in a couple of months or...
No.
OK, bag her.
Yellow on the end-tidal.
- Sorry, got backed up. - Sounds a little wet.
Someone asked for a surgical consult?
That's because all the fluid.
TKO the lines for now.
Vent settings 50%, tidal volume 500, AC 12?
Yep, that's perfect.
Surgery here. Hello.
Hey, it's about time. Where's Garcia?
Stuck in the ER. She sent me down. What you got?
Septic shock, respiratory failure,
and possible necrotizing fasciitis.
She needs to go to the OR ASAP.
The infection was isolated to the dorsum of the foot
five hours ago, but now we're almost to the knee
with bullae, crepitus, and edema.
- Yeah. - You seen nec fasc before?
In a textbook.
I was a med student two weeks ago.
- Gotta show this to Dr. Garcia. - OK. OK. Jesus Christ.
Go get anybody else from your service down here...
Shamsi, Miller, Walsh...
I don't know any of this people, but...
Don't take this personally.
I just need a fucking grown-up down here.
Nice job on the sub-Qs.
Really took the tension off the wound.
Thanks.
I can help with the skin layer.
Four hands are faster than two.
- Whoa. - Whoa.
That just tore right through the skin.
You may need to take bigger bites
farther away from the wound edges.
Yep.
Skin seems pretty fragile.
Oh.
Yeah, this is not working.
He has the skin strength of an 80-year-old.
Put down Steri-Strips with benzoin,
not across the wound but along each wound edge, both sides.
It'll hold the sutures.
- Yup. - What say you, Dr. Robby?
Great. MacGyver move.
Go for it.
Does a Dr. MacGyver work here?
I don't know.
The patient symptoms are consistent with lumbar
radiculopathy at L4, L5, most likely due to disc herniation.
Coughing patient admitted to isolation
for verified medication administration
and started on RIPE therapy.
Yeah, why do I even bother?
Just fail me now.
OK.
Get in touch with a social worker.
They're gonna wanna do contact tracing
and help her figure out transitional housing
for when she's discharged.
Got it.
And make sure infection control responded.
The people in the waiting room could have been exposed.
They need to be notified and tested.
OK.
Relax.
You can take the mask off. You don't have TB.
At least not yet.
Oh, great.
This is fucked up.
How are you so calm?
Expected job hazard.
You get used to it.
Yeah, no, thanks.
70% of doctors in training at urban hospitals
get exposed to TB and wind up on meds.
- Jesus. - Mm-hmm.
They don't teach you that in med school.
Mrs. Randolph's back.
Pulled up her X-ray.
OK.
No volvulus, no air fluid levels.
What do you think of this?
Fecal material?
A shit ton.
Sorry, had to be said.
So, what, she needs an enema?
No. Tried and failed, remember?
Yeah.
Time to dig in.
How are we gonna do that?
Oh, there is no "we" in disimpaction.
I haven't done one before.
Shouldn't I observe first?
I know just the guy to teach you.
I spoke to the charge nurse in med-surg.
They can take Orlando today.
- Yes! - That's wonderful.
They know he's on an insulin drip?
They know, and they can change to a SQUID protocol.
SQUID?
Sub-Q insulin in DKA.
So no IV drip?
Just shots of short-acting insulin every four hours prn.
The med-surg nurses have time to check a glucose every hour?
They say so.
And five days on med-surge
is gonna cut your hospital bill down by 2/3.
OK.
So what's that gonna cost?
Well, I can't give you an exact amount,
but roughly $35,000.
So after about 40%, I'll still have to pay,
what, like, 20 grand?
The hospital can work out a payment plan.
Orlando, we'll be OK.
We'll figure it out.
I'll take on extra shifts at the coffee shop.
We got you, Dad.
Let's give you some private time with your family.
Thanks.
Sorry. Thank you.
I was worried he might bail.
My pleasure.
The real thanks goes to the newbie here
for thinking outside the box.
Sorry I doubted your med-surg pitch.
Oh, no sweat.
How'd you think of that?
My family had to think of a lot of creative ways
to help my uninsured grandma.
Leukemia.
System doesn't work for you, you gotta work the system.
She survive?
For a while, till she didn't.
She died before my freshman year in college.
Sorry.
Her death taught me a lot.
Mainly that I don't wanna be around people dying.
So they got her, and we can get out of here soon?
Yeah. Oh, I think so.
- I think so, yeah. - OK.
Hi.
Morphine PCA looks ready to go.
This should do the trick.
Do you notice a difference?
Better.
Oh, great. Great.
How does this thing work?
There's a baseline rate of morphine.
And if you're having pain, you can push this button.
You'll get some extra.
And you can push for another dose
every 10 minutes if needed.
Your very own morphine butler.
Amazing.
She can go home with this?
Yeah.
Though you'll need more equipment for the house
now that she can't bear weight on her leg.
OK. Like what?
A wheelchair to go to the bathroom, a shower chair,
wall bars, if you don't already have them.
And a hospital bed could be helpful too.
How do we get all that?
You don't. I do.
I will get everything so that the two of you
can get out of here and back to the kids.
- At home. - Thank you.
Nice of you to join us, Huckleberry.
What do you need?
Some help with a disimpaction.
That is a med student procedure.
Oh, you know the old adage...
see one, do one, teach one.
Say hello to teaching young Ogilvie here.
OK.
- Double glove, Ogilvie. - All right.
Mrs. Randolph, we're going to need
to manually unblock your rectum so that we can
get your bowels moving again.
I know.
Here we go.
Mrs. Randolph, I would like you to relax
like you're having a bowel movement.
Nice and deep.
OK.
Curve the finger like an ice cream scoop.
And bring it out.
You're up, Ogilvie.
Some more pressure, Mrs. Randolph.
I'm ready.
And here I thought you weren't a quick study.
Keep going.
Mrs. Randolph, in order to prevent this
from happening again, I think you
need a better stool softener.
You can try MiraLAX.
Just a tablespoon with a big glass of water every morning
should do the trick.
OK.
Oh.
Sorry.
Passing gas is good.
Means we're making progress.
Does that mean that I can... I can stop?
No. Nope. Keep going.
OK, Ogilvie, you... you might wanna...
Oh!
Much better.
MAP's holding on Levophed.
1 mike per kg per minute.
Do me a favor.
Give me some 4x4s on some Betadine.
Sorry, we're getting killed
with transfers from Westbridge.
Mesenteric ischemia, perforated bowel.
Got a hot one here.
Yeah.
Possible nec fasc.
Possible?
Need CT with contrast to confirm.
This is spreading like wildfire.
By the time you get your CT, it's gonna be up to her waist.
She's gonna need a hemicorporectomy.
She needs a CT scan.
How about a stainless steel scan?
For Christ's sake. Robinavitch!
Robby, what the fuck are you doing?
Oh, God, I think I might puke.
That's called dirty dishwater exudate without purulence.
There's a gray appearance to the fascia, and in the OR,
you'll see easy separation in the tissue planes.
When do you start your sabbatical?
- Tomorrow. - Not a moment too soon.
Thanks for coming down.
I'm catching up on my charting as fast as I can.
Why don't you give my generative AI app a try?
It's 30% more efficient, and providers report
increased job satisfaction.
And you'll rarely have to stay overtime to complete charts.
Yeah?
OK.
Yeah, I'm usually here at least a couple hours
after every shift trying to catch up, so...
Sure, AI will make doctors more efficient,
but hospitals will expect us to treat more patients
without any extra pay, of course,
all the while eliminating staff positions
for attending and residents.
Oh, Dr. Robby, I am not an advocate
for erasing my own profession.
But I am advocating for getting to spend more time with my son.
Nothing can replace family.
What's the status of your septic patient?
Nec fasc. Surgery's taking her up.
Think they'll be able to save her leg?
Right now, I'm just hoping they can save her life.
Hey, how's Ogilvie doing?
A little TB exposure, a touch of ass-plosion.
All in all, pretty good day so far.
Kaison, you came.
Hey, ain't no way I was gonna let you
miss Peter and Aubrey's epic Fourth of July party.
Come on, now. Hey.
Brought some brew.
Oh, you are the man.
Appreciate the bromance over here,
but no food 'cause you might go into surgery.
And no beer 'cause we're a goddamn hospital.
Starting your sabbatical early?
I know someone who could really use a drink right now.
In the hospital?
As a parting gift.
How's it looking?
Good.
The Steri-Strips did the trick.
CT's ready.
We already scanned him.
Head and neck want thin cuts and a 3D reconstruction
of the mandible before they decide
if Mr. Varney needs surgery.
Have they even come down to examine him in person?
No, they must be backed up.
Or there's a July Fourth sale at the BMW dealership.
Labs are back.
Albumin's low. Total protein's low.
He also has megaloblastic anemia.
- Malnutrition. - Probably.
Jail cuisine.
Whitaker, what labs should we add?
B12, folate, iron levels.
Good.
We're gonna run some more tests, Mr. Varney.
Hang in there.
I have to pee.
There's no PureWick here.
But here you go, hon.
- I'll help you get on. - No. No.
No bedpan. I can walk to the bathroom.
- I just need a little help. - Are you sure?
I'm here, babe.
Oh, we got this Mr. Hamler.
You'll have to bring your IV and portable oxygen.
Please?
I'll grab a wheelchair.
Let's try to sit you up and dangle your legs.
OK.
1, 2, 3.
This is not a good idea.
I don't think we're gonna need this.
Hey, Paul, Paul,
why don't you come grab a cup of coffee with me?
I'm still zonked from my all-nighter,
and I wanna go over some delivery instructions with you.
Sure.
Rox, you OK?
- Mm-hmm. - Yeah. It's OK.
Bedpan it is.
You lose your pulse ox again, bud?
Louie.
Louie!
He kept pulling off his pulse ox.
It's on. It's at 71.
Louie, wake up.
- I'm not getting a carotid. - I got the airway.
Hey, Perlah, crash cart, intubation tray, please.
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